VALUE OF ROUTINE EVALUATION OF THE VOIDING PHASE WHEN PERFORMING URODYNAMIC TESTING IN WOMEN WITH LOWER URINARY TRACT SYMPTOMS

Videourodynamics - role, benefits and optimal practice

Videourodynamics (VUDS) is an advanced diagnostic procedure that simultaneously combines functional and anatomical evaluation of the lower urinary tract. The goal of this synchronous assessment is to promote accurate diagnosis of the aetiology responsible for patient symptoms, improving therapeutic decision-making. Overall, high-quality VUDS is advocated when other tests such as traditional urodynamics might not provide sufficient data to guide therapy, particularly in patients with complex, persistent or recurrent dysfunctions of the lower urinary tract. Additionally, VUDS is often crucial in the follow-up monitoring of many patients with these dysfunctions. A VUDS study is frequently considered a gold standard in patients with neurogenic lower urinary tract dysfunction, female bladder outlet obstruction or congenital anomalies of the lower urinary tract. Nevertheless, this specialized test should be limited to patients in whom VUDS data add value. Particularly, reliable studies comparing the effect of diagnosis with and without imaging on management outcomes are lacking, and no standardized procedures for undertaking VUDS are available. Additionally, patients should be carefully selected for VUDS evaluation, considering the increased cost and risks associated with radiological imaging. In routine practice, clinicians should balance the additional value of synchronous imaging and the enhanced diagnostic precision of VUDS against the limitations of this approach, which mainly include an uncertain effect of VUDS on final treatment outcomes.

Diagnostic value of voiding scores of the "International prostate symptom score" and the "Bristol female lower urinary system symptoms-short form" questionnaires in women with voiding dysfunction

Introduction

We aimed to investigate the diagnostic value of International Prostate Symptom Score voiding symptom score (IPSS-VS) and Bristol Female Lower Urinary Tract Symptoms-short form voiding score (BFLUTS-VS) in female patients with urodynamically diagnosed voiding dysfunction.

Methods

The medical records of female patients who underwent urodynamic examination between May 2007 and November 2021 for lower urinary tract complaints were retrospectively evaluated. A total of 1858 female patients were included in the study. Patients investigated between 2007 and 2014 were asked to fill the IPSS, and patients investigated after 2015 were asked to fill the BFLUTS-SF.

Results

The mean age of the patients was 49.06 ± 0.33 in the IPSS group and 50.02 ± 0.47 in the BFLUTS group. On the pressure flow study, voiding dysfunction was found in 14.8% (n = 95) in the IPSS group and 15.1% (n = 183) in the BFLUTS group. The area under curve value was found to be 0.58 for IPSS and 0.64 for BFLUTS. Threshold values were found as >9 for IPSS-VS and >4 for BFLUTS-VS. The sensitivity, specificity, false negative, and false positive rates for IPSS-VS were 33.3%, 78.8%, 66.7%, and 21.2%, respectively. The same parameters were 45.5%, 78.9%, 54.5%, and 21.1% for BFLUTS-VS, respectively.

Conclusion

The diagnostic performance of both the questionnaires was found to be low for diagnosing voiding dysfunction in female patients according to our data. Therefore, the assessment of the voiding phase in women should not solely rely on the current questionnaires. However, further studies using questionnaires including all voiding symptoms are required.

Is biofeedback-assisted pelvic floor muscle training superior to pelvic floor muscle training alone in the treatment of dysfunctional voiding in women? A prospective randomized study

Purpose:

To compare the effectiveness of biofeedback-assisted pelvic floor muscle training (PFMT) and PFMT alone on voiding parameters in women with dysfunctional voiding (DV).

Materials and Methods:

The patients in group 1 (34 patients) were treated with biofeedback-assisted PFMT, and the patients in group 2 (34 patients) were treated with PFMT alone for 12 weeks. The 24-hour frequency, average voided volume, maximum urine flow rate (Q_max), average urine flow rate (Q_ave), post-void residual urine volume (PVR), and the validated Turkish Urogenital Distress Inventory (UDI-6) symptom scores were recorded before and after 12 weeks of treatment.

Results:

At the end of treatment sessions, the Q_max and Q_ave values of the patients in group 1 were significantly higher than those in group 2, and the PVR in the patients in group 1 was significantly lower than those in group 2 (p=.026, .043, and .023, respectively). The average UDI-6 symptom scores of the patients in group 1 were significantly lower than those in group 2 (p=.034). Electromyography activity during voiding, in group 1 was significantly lower than in group 2 (41.2 vs. 64.7, respectively, p=.009).

Conclusion:

Biofeedback-assisted PFMT is more effective than PFMT alone in improving clinical symptoms, uroflowmetry parameters, and EMG activity during voiding.

In women with incontinence, the need for pressure-flow study before surgery and abnormalities in the voiding phase. An up-to-date comment on the available problem accompanied by literature

OBJECTIVE

To investigate the differences between urodynamic findings and history in women with urinary incontinence before surgery and clarify the need for preoperative pressure-flow studies.

MATERIALS AND METHODS

The medical records of 1018 women who underwent urodynamic examination for urinary incontinence between 2010 and 2015 were evaluated retrospectively. Stress (n = 442), urge (n = 334) and mixed (n = 242) were classified as type urinary incontinence according to urodynamics. The voiding phase findings of the patients were examined.

RESULTS

The mean age of the patients was 47.85 ± 0.27 years. 18.4% of patients (n = 187) had voiding phase problems. Furthermore, this condition was seen in the most urge incontinence type urinary incontinence (35%). There was a statistically significant difference between the groups' voiding phase findings (p < 0.0001). The relationship between the patient's history and international consultation on incontinence questionnaire form scoring (ICIQ) and the urodynamics results showed no excellent correlation.

CONCLUSIONS

Voiding phase abnormalities are not uncommon in patients with urinary incontinence. They should be considered in the evaluation of patients. Voiding phase findings may show significant differences between urodynamic data and history. Besides, the data obtained with the questionnaire forms were significantly different from the findings obtained by urodynamics. Consequently, urodynamics may change pre-operative clinical decision.

Therapeutic efficacy of biofeedback pelvic floor muscle exercise in women with dysfunctional voiding

Dysfunctional voiding (DV), a voiding dysfunction due to hyperactivity of the external urethral sphincter or pelvic floor muscles leading involuntary intermittent contractions during voiding, is not uncommon in neurologically normal women with lower urinary tract symptoms (LUTS). We aimed to investigate the therapeutic efficacy of biofeedback pelvic floor muscle training (PFMT) in female patients with DV and to identify the therapeutic efficacy. Thirty-one patients diagnosed with DV. All participates completed the 3-month biofeedback PFMT program, which was conducted by one experienced physiotherapist. At 3 months after treatment, the assessment of treatment outcomes included global response assessment (GRA), and the changes of clinical symptoms, quality of life index, and uroflowmetry parameters. 25 (80.6%) patients had successful outcomes (GRA ≥ 2), and clinical symptoms and quality of life index significantly improved after PFMT. Additionally, uroflowmetry parameters including maximum flow rate, voided volume, voiding efficiency, total bladder capacity, voiding time, and time to maximum flow rate significantly improved after PFMT treatment. Patients with the history of recurrent urinary tract infection in recent 1 year were found to have unsatisfied therapeutic outcomes. In conclusion, biofeedback PFMT is effective in female patients with DV with significant improvements in clinical symptoms, quality of life, and uroflowmetry parameters. The history of urinary tract infection in recent 1 year is a negative predictor of successful outcome.

Videourodynamic analysis of the urethral sphincter overactivity and the poor relaxing pelvic floor muscles in women with voiding dysfunction

AIMS

Voiding dysfunction due to dysfunctional voiding (DV) and poor relaxation of the external sphincter (PRES) are commonly found among adult women with lower urinary tract symptoms (LUTS) during videourodynamic study (VUDS). This study analyzed the VUDS characteristics of DV and PRES in female voiding dysfunction.

METHODS

This retrospective study involved 1914 women aged >18 years with refractory LUTS. The medical records and the VUDS parameters were reviewed. Patients diagnosed with DV and PRES participated in the study. The VUDS characteristics and urethral sphincter activities were compared with those of urodynamically normal women.

RESULTS

Of the 1914 women, 325 (17.0%) and 336 (17.6%) were diagnosed with DV and PRES, respectively. Detrusor overactivity (DO) occurred in 60% of the women with DV and in 5.7% of the women with PRES. Patients with DV had significantly increased bladder sensation, lower cystometric bladder capacity (CBC), lower bladder compliance, higher voiding detrusor pressure, smaller voided volume (VV), larger post-void residual volume (PVR), lower voiding efficiency (VE), and higher bladder outlet obstruction index (BOOI) than the women with PRES and the control individuals. Patients with PRES had significantly increased bladder sensation, lower CBC, lower maximum flow rate, smaller VV, larger PVR, and lower VE than the control individuals.

CONCLUSIONS

DV and PRES were highly prevalent among the adult women with voiding dysfunction. Patients with DV had VUDS characteristics of BOO and urodynamic DO. The clinical symptoms of PRES were similar to those of DV, but the patients had low detrusor contractility and low DO rates.

Dysfunctional voiding

PURPOSE OF REVIEW

Female dysfunctional voiding (FDV) is an intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the periurethral striated or levator muscles during voiding in neurologically normal women. Despite its codified definition, because of variable causes, there is a lack of established diagnostic criteria and management. The aim of this study is to give a comprehensive, brief review of the most recent progress in the diagnosis and management of FDV.

RECENT FINDINGS

Currently, there is the need to shed light on several issues in FDV, such as the use of standardized definitions, diagnostic criteria, and treatment modalities. The evaluation of the progress on these matters within 2013 helped to define some key advances in the field of female functional voiding dysfunction and urinary retention.

SUMMARY

In 2013, many diagnostic and therapeutic questions in female voiding dysfunction remain unsolved. However, some data began to emerge. Patients with FDV did not demonstrate a difference in effortful control (effortful control is the ability to regulate one's responses to external stimuli), but did demonstrate a higher rate of surgency (surgency is a trait aspect of emotional reactivity in which a person tends towards high levels of positive affect). Toilet training method in childhood does not seem to have any long-term correlation with FDV. Training with pelvic floor physiotherapy and biofeedback still represents the first-line treatment for FDV. In the management of other causes of female voiding dysfunction, sacral neuromodulation demonstrated a satisfying long-term efficacy in the treatment of nonobstructive urinary retention.

Urodynamic differences between dysfunctional voiding and primary bladder neck obstruction in women

OBJECTIVE

To determine the clinical and urodynamic differences in the presentation and the value of simultaneous fluoroscopy in dysfunctional voiding (DV) and primary bladder neck obstruction (PBNO); the 2 most common causes of non-neurogenic "functional" bladder outlet obstruction in women.

METHODS

A review of our urodynamic study database (March 2003 to August 2009) was conducted. DV was diagnosed when increased external sphincter activity was found during voluntary voiding on electromyography (EMG) or fluoroscopy. PBNO was diagnosed when a failure of bladder neck opening was noted on fluoroscopy during voiding. The demographics, symptoms, and urodynamic study parameters were collected. Comparisons were done using chi-square and 2-tailed t-tests.

RESULTS

DV was diagnosed in 34 women and PBNO in 16. The patients with DV were younger than those with PBNO (40.9 vs 59.2 years, P < .001). Women with DV showed a clinical trend toward having more storage symptoms than those with PBNO and fewer voiding symptoms. Patients with DV had a greater mean maximal flow rate (12 vs 7 mL/s, P = .027) and lower mean postvoid residual urine volume (125 vs 400 mL, P = .012). No significant differences were found in maximal detrusor pressure, detrusor pressure at maximal flow rate, or detrusor overactivity. EMG showed increased activity during voiding in 79.4% of those with DV and 14.3% of those with PBNO (P < .001).

CONCLUSION

Clinically, women with DV and PBNO had similar presentations, although those with PBNO had poorer emptying. The flow rates and patterns seemed to differ between those with DV and PBNO, although the voiding pressures were similar. EMG alone would have given the wrong diagnosis in 20.6% of those with DV (false negative) and 14.3% of those with PBNO (false positive). When fluoroscopy is used to define these entities, the accuracy of EMG to differentiate them is questionable.

International Prostate Symptom Score for assessing lower urinary tract dysfunction in women

INTRODUCTION AND HYPOTHESIS

Some lower urinary tract dysfunction (LUTD) subtypes may have similar symptoms. This study aimed to investigate the feasibility of using the International Prostate Symptom Score (IPSS) to evaluate lower urinary tract symptoms (LUTS) in women.

METHODS

All consecutive women with non-stress urinary incontinence LUTS who visited the urologic clinics for treatment were prospectively enrolled. LUTS include urinary storage, voiding, and post-micturition symptoms. All enrolled patients were requested to complete the Overactive Bladder Symptom Score (OABSS) and the modified Indevus Urgency Severity Scale (IUSS) questionnaires as well undergo uroflowmetry and post-void residual testing. A videourodynamic study was also performed, if indicated, for LUTD.

RESULTS

A total of 222 women were enrolled, including 60 with overactive bladder (OAB) dry, 42 with OAB wet, 78 with bladder oversensitivity, and 42 with voiding dysfunction. A significantly higher IPSS voiding to storage subscore ratio (IPSS-V/S) and IPSS voiding score were found in the voiding dysfunction group. IPSS-V/S was found to have the highest area under the receiver-operating characteristic curve for predicting voiding LUTD than other noninvasive methods, and an IPSS-V/S of ≥1.33 had the best predictive value for female voiding LUTD with a high negative predictive value (97.4 %). In addition, significantly higher IPSS storage subscore (IPSS-S) values were found in the OAB wet subgroup, and the IPSS-S was well correlated with the OABSS and IUSS.

CONCLUSIONS

The IPSS can be used to evaluate female LUTD. IPSS-V/S may provide an initial guide for the treatment of voiding dysfunction in women. In addition, IPSS-S may be used for evaluating storage LUTD in women.

The influence of preoperative bladder outlet obstruction on continence and satisfaction in patients with stress urinary incontinence after midurethral sling

PURPOSE

We studied the influence of preoperative bladder outlet obstruction (BOO) on postoperative continence rates and patient satisfaction after the midurethral sling procedure.

METHODS

A total of 159 women who underwent the midurethral sling procedure were evaluated. Using the Blaivas-Groutz nomogram, we assigned the patients were assigned to Group I (n=37, no obstruction), Group II (n=89, mild obstruction), or Group III (n=33, moderate to severe obstruction). Continence rates, patient satisfaction, urinary sensation scale and uroflowmetry were evaluated postoperatively.

RESULTS

There were no significant differences in continence rates, satisfaction, or postoperative maximal flow rate between the 3 groups. Postoperative urgency was improved after surgery in Groups I and II (P<0.05) but not in Group III.

CONCLUSIONS

BOO does not seem to be a risk factor for failure after the midurethral sling procedure. However, BOO may be considered as a potential factor for persistent storage symptoms after the midurethral sling.

Normal preoperative urodynamic testing does not predict voiding dysfunction after Burch colposuspension versus pubovaginal sling

PURPOSE

Urodynamic studies have been proposed as a means of identifying patients at risk for voiding dysfunction after surgery for stress urinary incontinence. We determined if preoperative urodynamic findings predict postoperative voiding dysfunction after pubovaginal sling or Burch colposuspension.

MATERIALS AND METHODS

Data were analyzed from preoperative, standardized urodynamic studies performed on participants in the Stress Incontinence Treatment Efficacy Trial, in which women with stress urinary incontinence were randomized to undergo pubovaginal sling surgery or Burch colposuspension. Voiding dysfunction was defined as use of any bladder catheter after 6 weeks, or reoperation for takedown of a pubovaginal sling or Burch colposuspension. Urodynamic study parameters examined were post-void residual urine, maximum flow during noninvasive flowmetry, maximum flow during pressure flow study, change in vesical pressure at maximum flow during pressure flow study, change in abdominal pressure at maximum flow during pressure flow study and change in detrusor pressure at maximum flow during pressure flow study. The study excluded women with a preoperative post-void residual urine volume of more than 150 ml or a maximum flow during noninvasive flowmetry of less than 12 ml per second unless advanced pelvic prolapse was also present.

RESULTS

Of the 655 women in whom data were analyzed voiding dysfunction developed in 57 including 8 in the Burch colposuspension and 49 in the pubovaginal sling groups. There were 9 patients who could not be categorized and, thus, were excluded from the remainder of the analysis (646). A total of 38 women used a catheter beyond week 6, 3 had a surgical takedown and 16 had both. All 19 women who had surgical takedown were in the pubovaginal sling group. The statistical analysis of urodynamic predictors is based on subsets of the entire cohort, including 579 women with preoperative uroflowmetry, 378 with change in vesical pressure, and 377 with change in abdominal and detrusor pressure values. No preoperative urodynamic study findings were associated with an increased risk of voiding dysfunction in any group. Mean maximum flow during noninvasive flowmetry values were similar among women with voiding dysfunction compared to those without voiding dysfunction in the entire group (23.4 vs 25.7 ml per second, p = 0.16), in the Burch colposuspension group (25.8 vs 25.7 ml per second, p = 0.98) and in the pubovaginal sling group (23.1 vs 25.7 ml per second, p = 0.17). Voiding pressures and degree of abdominal straining were not associated with postoperative voiding dysfunction.

CONCLUSIONS

In this carefully selected group preoperative urodynamic studies did not predict postoperative voiding dysfunction or the risk of surgical revision in the pubovaginal sling group. Our findings may be limited by the stringent exclusion criteria and studying a group believed to be at greater risk for voiding dysfunction could alter these findings. Additional analysis using subjective measures to define voiding dysfunction is warranted to further determine the ability of urodynamic studies to stratify the risk of postoperative voiding dysfunction, which appears to be limited in the current study.

Does the tension-free vaginal tape procedure (TVT) affect the voiding function over time? Pressure-flow studies 1 year and 3(1/2) years after TVT

AIM

The aim was to evaluate the voiding function over time after the TVT procedure for stress incontinence.

MATERIALS AND METHODS

Thirty-eight women with urodynamic stress urinary incontinence were included in the study. For voiding function assessment the patients were asked if voiding had changed postoperatively, and objectively uroflowmetry, residual urine measurement and pressure-flow were performed preoperatively, 1 year and 3(1/2) years postoperatively.

RESULTS

At 1/3(1/2) years follow-up 87%/69% were subjectively cured and 13%/26% improved, respectively. The objective cure rate was 89%/74%. Subjectively 77%/63% of the patients felt an altered voiding function towards more difficult voiding one and 3(1/2) years after surgery, respectively. Objectively all the uroflowmetry variables deteriorated and residual urine volume increased over time although the changes were not statistically significant between the 1 and 3(1/2) years follow-up. Pressure-flow variables were essentially unchanged.

CONCLUSION

The changes in voiding function after a TVT do not reverse over time. This may imply a potential risk of development of clinically important impaired emptying function.

Influence of intravesical potassium on pelvic floor activity in women with overactive bladder syndrome: comparative urodynamics might provide better detection of dysfunctional voiding

OBJECTIVES

To assess the influence of intravesical potassium on pelvic floor activity (PFA) during voiding in women with symptoms of overactive bladder (OAB), by using comparative urodynamics (CUD).

PATIENTS AND METHODS

The study included 175 women who met the criteria of OAB (mean age 52.7 years, range 18-87). CUD included two sessions of pressure-flow studies (0.9% saline vs 0.2 m KCl) with simultaneous measurement of PFA using perineal electromyography (EMG) with surface electrodes. Dysfunctional voiding (DV) was diagnosed if significant PFA was measured by EMG during voiding.

RESULTS

In 44 patients (25%) there was increased EMG activity only in the presence of KCL; in 58 (33%) there was DV with increased PFA during filling with saline. In all these patients PFA was significantly greater in the presence of KCl (P < 0.001). In patients with DV, filling with KCl prompted a statistically significant difference in maximum bladder capacity, maximum flow rate, mean flow rate and postvoid residual urine volume (P < 0.05). In summary, 102 patients (58%) had DV.

CONCLUSION

These findings suggest that DV is associated with epithelial dysfunction of the bladder mucosa, which clinically leads to OAB syndrome and can be revealed by CUD. The detection of DV might elude conventional urodynamics, but can be significantly enhanced by CUD (0.9% saline vs 0.2 m KCl).

Influence of intravesical potassium on pelvic floor activity in women with recurrent urinary tract infections: comparative urodynamics might lead to enhanced detection of dysfunctional voiding

OBJECTIVES

To investigate the influence of intravesical potassium on pelvic floor activity (PFA) during voiding in women with recurrent urinary tract infections (rUTIs) by using comparative urodynamics (CUD).

PATIENTS AND METHODS

CUD was conducted in 49 women (mean age 34.6 years, range 15-82) with rUTI. Every patient had two sessions of pressure-flow studies with simultaneous measurement of PFA by perineal surface electromyography (EMG); the first was with 0.9% saline and in the second the bladder was filled with 0.2 m KCl solution. All patients had voiding cysto-urethrography, and dysfunctional voiding (DV) was diagnosed when significant PFA was measured by EMG during voiding.

RESULTS

Overall, DV was diagnosed in 37 patients (76%) using CUD; 16 (32%) had DV with saline on the pelvic floor EMG. In all these patients there were significantly greater EMG signals in the presence of KCL. In 21 patients (43%) DV was only detected using KCL; this improvement in the detection rate of DV was statistically significant (P = 0.006). Filling with KCl also prompted a statistically significant difference (P < 0.05) in maximum bladder capacity, maximum and average flow rates and in postvoid residual urine volume.

CONCLUSION

The present data show that DV is present in most women with rUTI but cannot sufficiently be diagnosed by conventional urodynamics with standard 0.9% saline. The present study suggests that CUD might enhance the detection rates of DV.

Correlation of bladder base elevation with pelvic floor hypertonicity in women with lower urinary tract symptoms

AIMS

To determine whether the bladder base elevation as revealed by cystogram under fluoroscopy is associated with pelvic floor hypertonicity or bladder outlet obstruction (BOO) in women.

METHODS

Sixty-two women who were referred to our videourodynamic laboratory for assessment of lower urinary tract symptoms (LUTS) were included in this retrospective analysis. Thirty-one of these women with bladder base elevation-revealed by cystogram under fluoroscopy during videourodynamic study-served as the experimental group, and another group of 31 women without bladder base elevation served as control. None of the patients had neuropathy, previous pelvic surgery or chronic urinary retention. The clinical symptoms, urodynamic diagnosis, and parameters were compared between the two groups.

RESULTS

The mean voiding pressure (Pdet.Qmax) and postvoid residual (PVR) were significantly greater, and maximum flow rate (Qmax) and voided volume were significantly lower in the bladder base elevation group. When a Pdet.Qmax of >or=35 cmH2O combined with a Qmax of <or=15 ml/sec in pressure flow study was used to diagnose BOO, significantly more patients in the bladder base elevation group had BOO than controls (51.6% vs. 9.7%, P=0.0003). Pelvic floor muscle electromyogram (EMG) was dyscoordinated during the voiding phase in 18 (58.1%) and 9 (29%) of the patients with and without bladder base elevation, respectively (P=0.0212).

CONCLUSION

Women with LUTS and bladder base elevation revealed in the filling phase of videourodynamic study had significantly higher voiding pressure and incidence of dyscoordinated pelvic floor EMG activities during voiding, suggesting a higher incidence of BOO and pelvic floor hypertonicity.

Comparison of diagnostic criteria for female bladder outlet obstruction

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Functional obstructed voiding in the neurologically normal patient

Voiding dysfunction is common and often is the result of urethral obstruction to urine flow. Obstruction can be due to failure of the sphincteric mechanism to sufficiently relax. Such functional obstructions may have smooth and/or striated muscle components. Identifying and characterizing functional bladder outlet obstruction enables the physician to effectively treat these symptomatic patients.

Pathophysiology and subjective symptoms in women with impaired bladder emptying

AIM

To assess the pathophysiology and subjective symptoms in female patients with impaired bladder emptying.

METHODS

Eighty-three consecutive female patients attending a urology clinic with postvoid residual urine of more than 100 mL were recruited. Free uroflowmetry, measurement of postvoid residual urine and pressure-flow study were performed in all patients. The detailed assessment of subjective symptoms and their bothersomeness to the patients were assessed using a self-administered questionnaire comprising 12 items: five associated with voiding symptoms, five with storage symptoms, and two with discomfort and pain on voiding. The questionnaire was applied to 83 patients with impaired bladder emptying, 41 patients with urinary incontinence, and 21 normal controls.

RESULTS

Although 77% of the patients with impaired bladder emptying consulted a urology clinic because of voiding symptoms, the remaining 23% complained of storage symptoms or symptoms other than lower urinary tract symptoms (LUTS). The pressure-flow study revealed the pathophysiology of impaired bladder emptying as impaired detrusor contraction in 68 patients (81.9%), and bladder outlet obstruction in 12 patients (14.8%). The assessment of subjective symptoms using the questionnaire revealed that the patients with urinary incontinence showed a high frequency only in storage symptoms; however, those with impaired bladder emptying revealed a high frequency not only in voiding but also in storage symptoms.

CONCLUSIONS

Female patients with impaired bladder emptying present with a wide range of lower urinary tract symptoms associated with both voiding and storage symptoms. To determine an appropriate treatment modality, the correct diagnosis of the underlying pathophysiology of impaired bladder emptying by pressure-flow study is of primary importance.

Urodynamic assessment of bladder-outlet obstruction in women

Bladder-outlet obstruction (BOO) in women has become an increasingly recognized entity over the past several years. This is partly because of the greater number of anti-incontinence surgeries being performed, which can infrequently result in iatrogenic obstruction; and partly because of improvements in the ability to diagnose and recognize BOO. In this review, the symptoms associated with BOO in women, and whether these symptoms can reliably predict the presence of BOO, will be discussed. The incidence of BOO following surgical anti-incontinence procedures and the urodynamic diagnosis of BOO in women, detailing the various criteria that have been proposed, are also reviewed.

Comparison of voiding parameters in men and women with lower urinary tract symptoms

AIM

The aim of this study was to compare voiding parameters by using urodynamic investigations in men and women with lower urinary tract symptoms (LUTS).

METHODS

A total of 164 individuals (76 men and 88 women) completed the International Prostate Symptom Score (IPSS) and underwent a detailed urodynamic investigation. Patients were stratified by voiding function, which included bladder voiding efficiency (BVE) of < 80% and of >or= 80%.

RESULTS

IPSSs were similar in the men and women except for voiding symptoms for those with a BVE of >or= 80% (12 for men vs. 9 for women, P=0.016). When voiding parameters were compared according to BVE in men and women, respectively, maximum flow rate (Q(max)) (P=0.002), average flow rate (Q(ave)) (P=0.003), voided volume (P=0.037), post-void residual (PVR) (P<0.001), and bladder outlet obstruction index (P=0.016) were different for men with a BVE of < 80% and men with a BVE of >or= 80%. However, for women with a BVE of < 80% or >or= 80%, PVR (P<0.001), detrusor pressure at maximum flow rate (P=0.022), and opening detrusor pressure (P=0.024) were different.

CONCLUSIONS

The voiding parameters of women differ from those of men according to voiding function. The present results show that a pressure-flow study may represent a difference according to BVE in women as well as in men. Our findings suggest that opening detrusor pressure in women reflects the urethral and detrusor during voiding phase accurately as detrusor pressure at maximum flow rate does.

Urodynamics in the era of tension-free slings: Defining the role

The role of urodynamics in the routine preoperative evaluation of women with stress urinary incontinence is controversial. The introduction of tension-free mid-urethral sling procedures has created a new paradigm in surgical management. The capability of performing these procedures on an ambulatory basis has created more uncertainty about the use of urodynamic testing. The long-term results of these procedures in patients with intrinsic sphincteric deficiency, mixed incontinence, and voiding dysfunction are not clearly known. This article reviews the mechanism of action and results of tension-free slings and proposes a rational role for urodynamic testing in patients considered for these procedures.

Voiding dysfunction in young, nulliparous women: symptoms and urodynamic findings

The objective was to determine urodynamic findings in young, premenopausal, nulliparous women with bothersome lower urinary tract symptoms and assess whether or not symptoms are predictive of specific urodynamic abnormalities. The records of 57 women were reviewed. Those with neurological disease or a primary complaint of stress incontinence were excluded. All completed the American Urological Association Symptom Index (AUASI) and underwent videourodynamics. Symptoms were compared in patients with and without bladder dysfunction and/or voiding phase dysfunction. Bladder dysfunction was diagnosed in 86% of patients with urge incontinence vs. 17% of those without (p<0.0001). Patients with voiding phase dysfunction had higher total and voiding AUASI scores. Occult neurological disease was later diagnosed in 4 women (24%) with urge incontinence and bladder dysfunction. Urge incontinence and voiding symptoms are frequently associated with urodynamically demonstrable abnormalities. Urge incontinence and bladder dysfunction may be a sign of occult neurological disease in this population. The presenting symptoms are useful in determining the utility of urodynamics in this population.

Voiding dysfunction in women with systemic lupus erythematosus

OBJECTIVE

We sought to explore bladder dysfunction in a cohort of women with systemic lupus erythematosus (SLE).

METHODS

We conducted a prospective study of 152 female patients with SLE during a 15-month period. The clinical status of SLE was determined according to the SLE Disease Activity Index (SLEDAI), and bladder function was evaluated by lower urinary tract symptoms and urodynamic studies. We adapted the American Urological Association (AUA) index questionnaire to assess lower urinary tract symptoms in patients, which were compared with those in 227 age-matched healthy women.

RESULTS

The proportion of individuals reporting urinary frequency, urgency, weak urinary stream, and incomplete emptying, as well as severe lower urinary tract symptoms (AUA index score >/=20), was significantly higher in the SLE group when compared with the control group. The AUA index score showed a modest correlation with the SLEDAI score (r = 0.35, P < 0.001) but not with patient age or disease duration. There was a significant relationship between central nervous system involvement and the AUA index score. The most common urodynamic finding was a small cystometric bladder capacity (<150 ml; n = 7 patients), followed by a subnormal urinary flow rate (<12 ml/second; n = 6 patients). In 3 of 7 patients with small cystometric bladder capacities, imaging studies documented a contracted bladder with marked hydroureteronephrosis.

CONCLUSION

Patients with SLE experience an increased prevalence of voiding dysfunction compared with healthy individuals. Voiding dysfunction can be attributable to either direct bladder involvement or other disease-related factors.

American Urological Association Symptom Index for lower urinary tract symptoms in women: correlation with degree of bother and impact on quality of life

OBJECTIVES

To determine first whether the American Urological Association Symptom Index (AUASI) correlates with the degree of bother caused by lower urinary tract symptoms (LUTS) in women and whether the association varies with a woman's age and continent status; and second, whether the AUASI and degree of bother caused by symptoms correlate with a woman's quality of life (QOL) and whether the association varies with a woman's age and continent status. LUTS occur in women and may produce significant bother and affect their QOL. The AUASI has been used to evaluate LUTS in female patients; however, its correlation with the degree of bother and QOL has not been clearly established in women.

METHODS

The charts of 1232 women who completed the AUASI, as well as the Symptom Problem Index and global QOL question, were reviewed. Spearman's rank order correlation was computed to assess the correlation between the AUASI and Symptom Problem Index. It was also computed after stratifying the women's age and continence status (continent versus incontinent). A linear regression model was applied, with the AUASI and Symptom Problem Index as the response variables and QOL as the continuous explanatory variable.

RESULTS

The mean age was 54.6 years. Six hundred women (49%) were incontinent. Spearman's rank order showed a strong correlation between symptoms and problems caused by symptoms (0.858, P <0.0001). The correlation existed throughout various age groups and was independent of coexisting incontinence. The symptoms correlated with QOL in a similar pattern.

CONCLUSIONS

The AUASI accurately described LUTS in women and, as with men, is a good indicator of the degree of bother and affect on QOL.

Assessing health care needs and clinical outcome with urological case complexity: a study using INTERMED

Urinary tract symptoms and, particularly, urinary incontinence are often chronic and complex conditions that cause diagnosis, treatment, and management problems. In many cases, psychosocial factors contribute to the development of a chronic condition. The authors investigated whether INTERMED, an instrument for assessing case complexity and health care needs, was able to identify such complex cases, to estimate the amount of comorbidity, and to predict clinical outcome for 31 consecutive patients suffering from urinary tract symptoms. To assess clinical outcome, the authors used the American Urologic Association Symptom Score, the Brief Symptom Inventory, and the Hospital Anxiety and Depression Scale. On the basis of the patients' INTERMED scores, the authors distinguished between low-complexity patients (INTERMED score <21, N=25, 80.6%) and high-complexity patients (INTERMED score >or=21, N=6; 19.4%). Low-complexity patients had fewer depressive and anxiety symptoms, less distress, and better clinical outcome at their 3-month follow-up than high-complexity patients. The data confirmed the ability of the instrument to detect patients at risk of complex urinary tract symptoms and to predict clinical outcome.

Video urodynamics using transrectal ultrasonography for lower urinary tract symptoms in women

AIMS

To understand the properties of lower urinary tract disorders in women, we evaluated 60 female patients with lower urinary tract disorders or symptoms of recurrent cystitis by free uroflowmetry and video urodynamics using transrectal ultrasonography (VU-TRUS).

METHODS

Results of urodynamic studies or symptoms of stress incontinence were used to divide 60 women into 7 normal controls and 53 with voiding dysfunctions.

RESULTS

In normal controls, VU-TRUS showed that the mean posterior urethrovesical angle and anteroposterior diameter of the proximal urethra at maximum flow was 151.4 degrees and 4.9 mm, respectively. In patients with voiding dysfunction, VU-TRUS during voiding revealed various urethral abnormalities, including 16 detrusor sphincter dyssynergia, 4 detrusor bladder neck dyssynergia, and 13 insufficient opening of the entire urethra. VU-TRUS also showed pelvic floor abnormalities, including 24 urethral hypermobilities (group 1) and 11 cystoceles (group 2). Eighteen patients had neither urethral hypermobility nor cystocele (group 3). Major pressure-flow abnormalities in the 53 patients with voiding dysfunctions were weak detrusor (72%) and/or bladder outlet obstruction (25%). There were no significant differences in the distribution of the pressure-flow abnormalities among the three groups. However, the mean values of abdominal pressure at maximum flow of group 1 (20.9 cm H(2)O) and group 2 (17.9 cm H(2)O) were significantly higher than that of group 3 (6.3 cm H(2)O; each P < 0.05). The mean values of residual urine volume of group 2 (60.8 mL) and group 3 (77.6 mL) were significantly higher than that of group 1 (23.5 mL; each P < 0.05).

CONCLUSIONS

The symptoms of women with lower urinary tract disorders were frequently accompanied by urethral and/or pelvic floor abnormalities during voiding that were clearly detected by VU-TRUS. VU-TRUS is useful for objective evaluation of female lower urinary tract symptoms.

Non-neurogenic female voiding dysfunction

PURPOSE OF REVIEW

The pathophysiological mechanisms of female voiding phase dysfunction are poorly understood, and there are neither standard definitions nor guidelines for diagnosis and treatment. The aim of this review is to present up-to-date data and controversies associated with non-neurogenic female voiding dysfunction.

RECENT FINDINGS

Conceptually, voiding phase dysfunction may have bladder or urethral causes. Bladder causes include detrusor contraction of inadequate magnitude or duration to effect bladder emptying (detrusor underactivity), or the absence of detrusor contraction (detrusor arreflexia). Urethral causes consist of bladder outlet obstruction as a result of urethral overactivity (functional obstruction), or anatomical (mechanical obstruction) pathologies. The specific prevalence and contribution of each of the above mechanisms is unknown. Furthermore, a correct and timely diagnosis may be difficult, because clinical features are very similar to those of other lower urinary tract symptoms, and diagnostic modalities are often inconclusive or even misleading. A full urodynamic evaluation is essential in making the diagnosis; however, standard urodynamic definitions are still lacking. In the following review, we will present recent findings associated with the prevalence, etiology and diagnosis of each of the different categories of female voiding phase dysfunction, and highlight new advances presented during the past year.

SUMMARY

Further epidemiological and pathophysiological investigations are needed to evaluate the causes and main risk factors of voiding dysfunction in women. A better understanding of the pathophysiological mechanisms associated with this challenging condition may provide the possibility to use appropriate diagnostic and treatment modalities, thus avoiding unnecessary interventions.

Does the tension-free vaginal tape procedure affect the voiding phase? Pressure-flow studies before and 1 year after surgery

OBJECTIVE

To evaluate the voiding phase before and 1 year after surgery in women who underwent a tension-free vaginal tape (TVT) procedure for stress incontinence.

PATIENTS AND METHODS

The study comprised 45 women with genuine stress urinary incontinence. To assess the voiding phase, patients were asked if their voiding had changed after surgery, and objectively the uroflowmetry, residual urine measurements and pressure-flow data were compared.

RESULTS

At 1 year after surgery 39 women (87%) were subjectively cured and six (13%) improved. The objective cure rate was 88%; the pad-test leakage and the number of leakage episodes decreased significantly after surgery. Subjectively, 78% of the patients reported that the voiding phase had become more difficult, and the spontaneous flow curve changed to a more obstructive pattern in 40%, with the mean urinary peak flow rate (Q(max)), the corrected Q(max) and the mean average flow rate decreasing significantly. The residual urine volume increased significantly, although no patient had volumes of > 25% of their bladder capacity. During the pressure-flow study the Q(max) decreased and the urethral resistance factor increased significantly. However, only one patient could be classified as obstructed. Two patients had clinical problems and used self-catheterization once daily 1 year after surgery.

CONCLUSION

There were subjective and objective changes in the voiding phase 1 year after the TVT procedure. The significance of these findings remains to be determined. Longitudinal studies are warranted to clarify whether the patients at risk can be characterized from subjective and objective findings.

Bladder outlet obstruction in women: prevalence, recognition, and management

Bladder outlet obstruction in women is an infrequently diagnosed urological condition. Its prevalence has been estimated to be between 2.7% and 29%. The large variation in prevalence is likely a result of the lack of standard diagnostic definition for the evaluation of female bladder outlet obstruction. A combination of history taking; physical examination; and diagnostic tests, including simple pressure void studies, radiographic imaging, endoscopic visualization, and multichannel videourodynamics provides a consistent way to accurately recognize and diagnose bladder outlet obstruction. Causes of obstruction are varied and numerous but generally fall within two broad categories: functional and anatomic. Treatment options are tailored to individual causes of obstruction and range from conservative pharmacologic and behavioral options to more-invasive surgical procedures.

Evaluation of female lower urinary tract symptoms: overview and update

Female lower urinary tract symptoms are nonspecific, and a thorough clinical evaluation is required to establish the correct diagnosis. Such evaluation should consist of a structured micturition history or questionnaire, physical examination with full bladder, micturition diary, pad test and urodynamic evaluation. The urodynamic evaluation should consist at least of cystometry, detrusor pressure/uroflow study, simple ('free') uroflowmetry, assessment of the relative contribution of urethral hypermobility and intrinsic sphincter deficiency, and estimation of postvoid residual urine by ultrasound or catheterization. Recent studies regarding the role of pad tests, micturition diaries and urodynamic studies in the evaluation of female voiding dysfunction are presented. Factors that are associated with the use of transurethral catheter during pressure-flow studies and current controversies regarding the diagnosis of female bladder outlet obstruction are reviewed and discussed. Although the urodynamic study is considered to be the best diagnostic tool in assessment of lower urinary tract function, some practitioners believe that urodynamic evaluation is not routinely warranted and prefer to employ a symptom-based empirical management strategy. Lower urinary tract symptoms are nonspecific, however, and should be used mainly to identify what bothers the patient. Urodynamic studies define the underlying pathophysiology. We believe that treatment of the underlying pathophysiology facilitates better treatment of symptoms.

Dysfunctional voiding in women

PURPOSE

We characterized presenting symptoms and urodynamic findings in women with dysfunctional voiding.

MATERIALS AND METHODS

We reviewed the charts of 26 women diagnosed with dysfunctional voiding. Those with a known or suspected history of neurological disease before evaluation were excluded from study. All patients completed an American Urological Association symptom index, and scores were classified as total, storage (irritative) and emptying (obstructive). The diagnosis of dysfunctional voiding was made on multichannel video urodynamics. There was increased external sphincter activity during voiding. Presenting symptoms and urodynamic findings in all cases were summarized. In addition, symptoms and urodynamic findings in patients later diagnosed with occult neurological disease were compared with those in patients without neurological disease.

RESULTS

Mean patient age was 39.2 years (range 19 to 79). Mean total American Urological Association-7 score was 24.4 of 35. Frequency and urgency were the most common presenting symptoms in 82% of cases. Mean storage score was 11.3 of 15 and mean voiding score was 13.2 of 20. Urge and stress incontinence was noted in 6 (23%) and 4 patients (15%), respectively, while 11 (42%) had a history of recurrent urinary tract infection. Cystometrography revealed detrusor instability in 11 cases (42%), sensory urgency in 11 (42%) and impaired compliance in 2 (8%), including 1 with instability. There was great variability in voiding parameters. Mean maximum urinary flow plus or minus standard deviation was 10.4 +/- 6.2 cc per second, mean detrusor pressure at maximum urinary flow was 50.3 +/- 23.5 cm. water and mean post-void residual urine volume was 103.4 +/- 120.0 cc. Video urodynamics prompted neurological evaluation, which revealed occult neurological disease in 5 patients who were then reclassified with external-detrusor sphincter dyssynergia.

CONCLUSIONS

Female patients presenting with lower urinary tract symptoms may have dysfunctional voiding patterns. Storage symptoms appear to be even more common than voiding symptoms in this study group. These patients tend to have decreased flow, increased voiding pressure and high post-void residual urine volume. However, there is wide variation in these parameters among individuals. Therefore, careful review of the voiding phase, including pelvic floor electromyography and the fluoroscopic appearance of the bladder outlet, is critical. Occult neurological disease should be suspected in patients with dysfunctional voiding.