Relationship between voiding pressures, symptoms and urodynamic findings in 253 men undergoing prostatectomy

AUA White Paper on Nonneurogenic Chronic Urinary Retention: Consensus Definition, Treatment Algorithm, and Outcome End Points

PURPOSE

The AUA (American Urological Association) QIPS (Quality Improvement and Patient Safety) committee created a white paper on the diagnosis and management of nonneurogenic chronic urinary retention.

MATERIALS AND METHODS

Recommendations for the white paper were based on a review of the literature and consensus expert opinion from the workgroup.

RESULTS

The workgroup defined nonneurogenic chronic urinary retention as an elevated post-void residual of greater than 300 mL that persisted for at least 6 months and documented on 2 or more separate occasions. It is proposed that chronic urinary retention should be categorized by risk (high vs low) and symptomatology (symptomatic versus asymptomatic). High risk chronic urinary retention was defined as hydronephrosis on imaging, stage 3 chronic kidney disease or recurrent culture proven urinary tract infection or urosepsis. Symptomatic chronic urinary retention was defined as subjectively moderate to severe urinary symptoms impacting quality of life and/or a recent history of catheterization. A treatment algorithm was developed predicated on stratifying patients with chronic urinary retention first by risk and then by symptoms. The proposed 4 primary outcomes that should be assessed to determine effectiveness of retention treatment are 1) symptom improvement, 2) risk reduction, 3) successful trial of voiding without catheterization, and 4) stability of symptoms and risk over time.

CONCLUSIONS

Defining and categorizing nonneurogenic chronic urinary retention, creating a treatment algorithm and proposing treatment end points will hopefully spur comparative research that will ultimately lead to a better understanding of this challenging condition.

Can Bladder and Prostate Sonomorphology Be Used for Detecting Bladder Outlet Obstruction in Patients With Symptomatic Benign Prostatic Hyperplasia?

OBJECTIVE

To investigate the accuracy of the bladder and prostate sonomorphologic parameters for the diagnosis of bladder outlet obstruction (BOO) in patients with lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

First-visit men, aged ≥ 50 years, with LUTS/BPH were prospectively enrolled. Added to the initial basic evaluation, all patients underwent pelvic ultrasonography and pressure flow study. The pressure flow study was used as a reference standard for BOO, and according to its results, patients were divided into BOO and non-BOO groups. The sonomorphologic findings were compared between both groups, and the diagnostic accuracy of the significant parameters was determined.

RESULTS

In total, 157 patients were included. Of these, 48 (30.57%) had BOO and 109 (69.43%) did not. Bladder wall thickness (BWT), ultrasound estimated bladder weight (UEBW), and intravesical prostatic protrusion (IPP) were the sonomorphologic parameters that differed significantly between both groups (P < .001). By receiver operating characteristic curve analysis, the optimal cutoff values distinguishing patients with BOO were BWT of 3.7 mm (area under the curve [AUC]: 0.940), UEBW of 31.5 g (AUC: 0.835), and IPP of 10.9 mm (AUC: 0.874). The sensitivity, specificity, and accuracy of BWT, UEBW, and IPP were 95.00%, 90.91%, and 93.55%; 75.44, 57.97%, and 65.62%; and 87.90%, 76.43%, and 82.17%, respectively.

CONCLUSION

BWT, UEBW, and IPP measurements can be used to detect BOO in LUTS/BPH patients. The simple estimation of these sonomorphologic parameters by suprapubic approach makes these measurements potentially suitable methods to judge BOO noninvasively during the routine clinical evaluation of BPH.

Acupuncture for Chronic Urinary Retention due to Spinal Cord Injury: A Systematic Review

No systematic review has been published on the use of acupuncture for the treatment of chronic urinary retention (CUR) due to spinal cord injury (SCI). The aim of this review was to assess the effectiveness and safety of acupuncture for CUR due to SCI. Three randomized controlled trials (RCTs) including 334 patients with CUR due to SCI were included. Meta-analysis showed that acupuncture plus rehabilitation training was much better than rehabilitation training alone in decreasing postvoid residual (PVR) urine volume (MD -109.44, 95% CI -156.53 to -62.35). Likewise, a combination of acupuncture and aseptic intermittent catheterization was better than aseptic intermittent catheterization alone in improving response rates (RR 1.23, 95% CI 1.10 to 1.38). No severe adverse events were reported. In conclusion, acupuncture as a complementary therapy may have a potential effect in CUR due to SCI in decreasing PVR and improving bladder voiding. Additionally, acupuncture may be safe in treating CUR caused by SCI. However, due to the lack of high quality RCTs, we could not draw any definitive conclusions. More well-designed RCTs are needed to provide strong evidence.

Noninvasive Methods of Diagnosing Bladder Outlet Obstruction in Men. Part 1: Nonurodynamic Approach

PURPOSE

Many methods have been suggested for diagnosing bladder outlet obstruction, as defined by the gold standard of pressure flow studies. Difficulty arises when comparing completely different methods of diagnosing bladder outlet obstruction. A comprehensive review of the literature of the different methods used to diagnose bladder outlet obstruction by noninvasive means was performed with a view to allow such a comparison.

MATERIALS AND METHODS

A MEDLINE search was done of the published literature covering until the end of 2004 on noninvasive methods used to diagnose bladder outlet obstruction. A direct comparison of all different methods was made using the sensitivity and specificity, positive predictive value and likelihood ratio of each test. For many of the techniques these values were calculated from the data presented in the article.

RESULTS

A multitude of methods has been applied to diagnose bladder outlet obstruction. Broadly the methods were divided into nonurodynamic and noninvasive urodynamic methods. Nonurodynamic methods include symptoms, biochemical tests such as prostate specific antigen, ultrasound derived measurements such as post-void residual urine, bladder weight, prostate configuration and size, intravesical prostatic protrusion and the Doppler resistive index. Part 1 of the review explores and discusses the relative merits of the nonurodynamic based methods.

CONCLUSIONS

Ultrasound derived measures such as bladder wall thickness and bladder weight offer a promising possibility of diagnosing bladder outlet obstruction noninvasively. However, further reproducibility and large accuracy studies with better methodological standards are required before they can replace pressure flow studies.

Transcutaneous electrical nerve stimulation in the treatment of neurological patients with urinary symptoms

OBJECTIVE

To determine whether transcutaneous electrical nerve stimulation (TENS) benefits patients with urinary symptoms caused by neurological diseases.

PATIENTS AND METHODS

Patients with urinary symptoms from any kind of neurological disease were prospectively recruited between October 1996 and July 1998. Before attending the first assessment patients were asked to complete a week's diary recording the frequency of micturition, incontinence episodes, and frequency of pad and clothes changing. At the first assessment the patients completed the Frimodt-Moller urinary symptom questionnaire, and quality-of-life scales including the Nottingham Health Profile and Short-Form 36. Demographic and disability data (Barthel Index and Frenchay Aphasia Screening Test) were recorded, and patients underwent a neurological examination and urodynamic studies. The placing of electrode pads on the sacral dermatomes 2.5 cm either side of and 2.5 cm above the natal cleft was demonstrated, and the patient instructed to use TENS for 90 min twice a day. The current strength applied was set to that which the patient could tolerate, at a square-wave of 20 Hz and 200-micros duration. Six weeks later the patients were further assessed, where the diary exercise, questionnaires and urodynamics were repeated. In all, 44 patients (13 men and 33 women, mean age 50.8 years) were recruited.

RESULTS

The commonest disease was multiple sclerosis and the commonest impairments para/tetraplegia or hemiplegia. There was no change in the neurological status of the 34 patients completing the study. Irritative voiding symptoms were significantly decreased (0.68-0.61, P = 0.003) and diaries also showed significant improvements in the 24 h frequency of micturition (P = 0.01), incontinence episodes (P = 0.04) and clothes changes (P = 0.02). Urodynamics showed detrusor hyper-reflexia in most patients. The only significant changes after TENS were an increased postvoid residual volume (from a mean of 134 mL to 160 mL, P = 0.03) and an increase in the volume leaked during the urodynamic study with TENS on (from a mean of 4.7 mL to 12 mL, P = 0.003). There were no significant changes in the quality-of-life scores. Of the 34 patients completing the study, half still reported a benefit from TENS at 1 year, although some patients found it took 3-4 weeks to work.

CONCLUSION

TENS applied to the sacral dermatomes of neurological patients with urinary symptoms had a minimal effect on urodynamic data but significantly improved irritative urinary symptoms, 24-h urinary frequency, incontinence and clothes changing. The lack of effect on quality-of-life measures probably reflects the lack of sensitivity in the tools used in this group of patients. We therefore recommend using TENS in this often problematical group of patients.

Relationship among symptom score, prostate volume, and urinary flow rates in 543 patients with and without benign prostatic hyperplasia

BACKGROUND

Studies on the relationship among symptom score, urinary flow rate, and prostate volume in men with lower urinary tract symptoms (LUTS) continue to be of great interest.

METHODS

A total of 2,418 men, aged 30-86 years, agreed to participate in an interview and to complete a questionnaire regarding voiding patterns. All subjects answering positively to one or more of the questions were submitted to a diagnostic assessment, based on the algorithm outlined by the guidelines of the International Consultation on Benign Prostatic Hyperplasia (BPH). Five hundred forty-three out of the 2,418 participants (22.45%) were evaluated. At the end of the diagnostic evaluation, 400 men with LUTS but without concomitant conditions (except BPH) known to interfere with normal voiding were selected. Descriptive statistics were used to characterize age, symptom score (International Prostate Symptom Score), prostate volume, and urinary flow rate distribution in these patients. Correlations among the aforementioned parameters were evaluated by means of a multivariate, multiple linear regression and logistic regression model.

RESULTS

As reported in other studies, only weak or modest correlations were found. Moreover, the 400 cases were classified according to four age decades. The decrease in peak and mean flow rate per decade of age was similar (0.5 and 0.4 ml/sec); the increase in prostate volume and in total symptom score per decade was 3.3 cc and 0.6, respectively. In patients less than 50 years old, most of the correlations were stronger than those observed in the entire population of 400 men (age and prostate volume, c.c. 0.2864; age and peak flow rate, c.c. -0.2689; age and mean flow rate, c.c. -0.3034). However, symptom score continued to be weakly correlated with age and prostate volume (c.c. 0.0498 and 0.1966, respectively). In the last part of the study, men were assigned to different treatment strategies. Patients who were assigned to surgical treatment had higher prostate volume and IPSS and lower urinary flow rate than those assigned to nonsurgical treatment.

CONCLUSIONS

We believe that the reason for the weak statistical association frequently reported in the literature is mainly the urology clinic-based population from which the patient samples were drawn. Data emerging from this analysis support the hypothesis that age is one of the principal factors influencing the relationship among symptom score, urinary flow rate, and prostate volume.

Limitations of epidemiologically based needs assessment. The case of prostatectomy

OBJECTIVES

The aim of this study was to make epidemiologically based estimates of the prevalent and incident "need" for prostatectomy for lower urinary tract symptoms, defined as the numbers of men who would both benefit from and want the operation.

METHODS

The methods involved a consensus panel, a two-stage postal survey of 1,480 men aged 55 years or older from eight general practices to the northwest of London, United Kingdom, and a multistate life table.

RESULTS

The overall response rate was 69% (initial survey: 78%, follow-up survey: 88%). A trial-based estimate of number of candidates for prostatectomy (men with symptoms that were at least moderately severe and bothersome and who would probably or definitely want surgery) was 610 men in a population of 250,000. The corresponding incidence estimate (including men with symptoms recurring after spontaneous remission or surgery) was approximately 200 per year, including approximately 110 new cases. Consensus-based estimation, including categories of patients who have not yet been subject to a trial, gave much higher figures of approximately 3,000, 650, and 200 candidates, respectively. Adding the number of men who said they were "inclined to" choose surgery would almost double these figures.

CONCLUSIONS

Estimates of need were highly sensitive to choice of indications and assumptions about patients' attitudes toward surgery. Population needs assessment for specific procedures will always involve judgment as well as epidemiological data and modeling.

The correlation between urodynamic and cystoscopic findings in elderly men with voiding complaints

PURPOSE

We evaluated the urethrocystoscopic findings and results of urodynamic studies in elderly men with voiding complaints.

MATERIALS AND METHODS

A total of 492 consecutive patients with voiding complaints underwent a standardized screening program, including transrectal ultrasonography of the prostate, urodynamic investigations with pressure-flow study analysis and flexible urethrocystoscopy.

RESULTS

A significant correlation was found between bladder trabeculation and grade of bladder outlet obstruction. Detrusor instability correlated significantly with grade of trabeculation. Grade of obstruction showed a clear correlation with prostatic occlusion of the urethra and the presence of a middle lobe at cystoscopy.

CONCLUSIONS

The findings at urethrocystoscopy correlate well with those of urodynamic investigations.

Urodynamic assessment in the laser treatment of benign prostatic enlargement

OBJECTIVE

To determine if bladder outlet obstruction can be adequately relieved after laser prostatectomy.

PATIENTS AND METHODS

Since November 1992, a total of 105 patients underwent laser treatment of the prostate because of complaints related to benign prostatic enlargement (BPE). To date, urodynamic data from a study of pressure flow analysis are available for 79 patients both at baseline and at 6 months after treatment. Patients were evaluated using changes in symptoms (IPSS symptom score), peak flow rate (Qmax), post-voiding residual volume (PVR), detrusor pressure at maximum flow (Pdet at Qmax), and the linear passive urethral resistance relation (LPURR). Moreover, patients with minimal bladder outlet obstruction were compared to patients with severe bladder outlet obstruction.

RESULTS

There was a significant improvement in mean IPSS score from 21.3 at baseline to 5.3 at the 6-month follow-up. The Qmax improved from 7.9 mL/s to 17.8 mL/s, and the PVR decreased from 91.6 mL to 15.6 mL. At baseline, > 80% of the patients were considered obstructed according to the analysis of pressure flow, whereas 6 months after laser treatment, only 5% of the patients were still considered obstructed. A comparison of the outcome between minimally obstructed patients and severely obstructed patients showed comparable improvements.

CONCLUSION

Laser therapy of the prostate was, according to urodynamic parameters, capable of relieving outlet obstruction and minimally obstructed patients also showed a significant relief of outlet obstruction.

Clinical outcome and quality of life following enterocystoplasty for idiopathic detrusor instability and neurogenic bladder dysfunction

OBJECTIVE

To study the long-term outcome of patients undergoing enterocystoplasty.

PATIENTS AND METHODS

The study comprised 48 patients (17 men and 31 women; mean age 46 years) who underwent enterocystoplasty for idiopathic detrusor instability (DI, 35 patients) or neurogenic bladder dysfunction (13 patients). Symptoms were scored from 0 to 14 and the overall outcome and generic quality of life were assessed using a Visick grading system (groups A to E) and the Nottingham Health Profile (NHP). These assessments were carried out before, 3 months after operation and at the final follow-up (38 +/- 18 months, range 13-78). Urodynamic studies were performed before and after operation.

RESULTS

No patient died after operation and there was minimal early morbidity. Late complications (> 30 days) included incisional hernia (3), anastomotic perforation (1), calculus formation (1) and urethral stricture (1). Clean intermittent self-catheterization (CISC) was performed by 36 (75%) patients. Early symptomatic outcome was good in 40 (83%) patients, moderate in seven (15%) and unsatisfactory in one (2%) patient. The mean symptom scores before and 3 months after surgery were 10 (range 2-14) and 3 (range 2-14), respectively (P < 0.001). There was a significant increase in total bladder capacity (307 +/- 140 to 588 +/- 217 mL; P < 0.001) and bladder compliance (37 +/- 50 to 169 +/- 162 mL/cm H2O; P < 0.001). DI persisted in 15 (31%) patients. NHP scores revealed significant improvements in all domains. Final assessment showed a less satisfactory situation, with recurrent urinary tract infection (UTI) in 17 (37%) patients, a need for long-term antibiotic therapy in seven (15%) and a change in bowel habit in 15 (33%) (13 DI, two with neurogenic bladder dysfunction). CISC was performed by 39 (85%) patients. The long-term outcome was good or moderate in 12 patients (92%) with neurogenic bladder dysfunction and good or moderate in only 19 patients (58%) with DI.

CONCLUSION

Clam enterocystoplasty remains an effective management option in some patients with DI, but most patients with neurogenic bladder dysfunction do well. The procedure is, however, associated with long-term complications such as disturbance of bowel habit and recurrent UTIs, which impair the outcome in the long-term in patients with DI despite general improvements in irritative bladder symptoms.

Urodynamic results of laser treatment in patients with benign prostatic hyperplasia. Can outlet obstruction be relieved?

PURPOSE

A urodynamic study was done to judge the capability of laser treatment to relieve bladder outlet obstruction.

MATERIALS AND METHODS

Advanced urodynamic studies with pressure-flow analysis were performed before and 6 months after laser treatment using 3 different laser devices.

RESULTS

Forty patients showed significant improvement in all obstruction parameters (detrusor pressure at maximum flow rate, urethral resistance relation, theoretical cross-sectional urethral area, minimal detrusor pressure and linear passive urethral resistance relation) together with significant subjective improvement in international prostate symptom score. After treatment 82 to 92% of the patients could no longer be considered to have obstruction. No difference in outcome among the devices used was found.

CONCLUSIONS

Laser prostatectomy is indeed capable of relieving bladder outlet obstruction.

The International Prostate Symptom Score in a community-based sample of men between 55 and 74 years of age: prevalence and correlation of symptoms with age, prostate volume, flow rate and residual urine volume

OBJECTIVES

To study the prevalence of symptoms of prostatism in the community and the correlation between these symptoms and age, prostate volume, flow rate and residual urine volume.

SUBJECTS AND METHODS

The International Prostate Symptom Score (IPSS) was administered to a community-based population of 502 men aged between 55 and 74 years with no prostate cancer and no history of a prostate operation. Prostate volume parameters, flow rate variables and post-void residual urine volume were measured.

RESULTS

Overall, 6 and 24% of the men were severely and moderately symptomatic, respectively. The results of a detailed questionnaire such as the IPSS (only 12% of the men scored 0) contrast with the men's global perception of their voiding function (82% claimed to have 'no voiding complaints'). A good correlation was found between the total symptom score and the single disease-specific quality of life question that is included in the IPSS (r = 0.74, P = 0.001). There was a weak correlation between the IPSS and total prostate volume (r = 0.19, P < 0.001), and between the IPSS and physiological measures such as peak flow rate (r = -0.18, P < 0.001) and post-void residual urine volume (r = 0.25, P < 0.001). There was a very weak correlation between the IPSS and age (r = 0.09, P = 0.04).

CONCLUSIONS

The parameters used to characterize benign prostatic hyperplasia (BPH) should be considered independently because no predictions about the value of a certain parameter can be made by knowing one of the other parameter values. Symptom scores should therefore not be used as a pre-selection criterion in the determination of the prevalence of clinical BPH without taking other measures into account. The interpretation of the parameter values in a clinical setting should take the lack of correlation and the variability of the parameter values into account.

Outcome of endoscopic bladder transection

OBJECTIVE

To determine the clinical, symptomatic and objective urodynamic outcome of patients undergoing endoscopic bladder transection.

PATIENTS AND METHODS

The study included 20 men and 30 women (mean age of 50 +/- 15 years, range 20-86) who underwent endoscopic bladder transection. Their underlying diagnoses were idiopathic detrusor instability (41), enuresis with instability (6), multiple sclerosis (2) and Parkinson's disease (1). A full-thickness endoscopic transection of the bladder was performed under general anaesthesia. Subjective assessment was performed using symptom scores (0-14 points) and a Visick grading system (group A-E). Objective assessment was carried out using urodynamic studies. The mean follow-up period was 6 years (57 +/- 22 months, range 6-85).

RESULTS

The mean hospital stay was 8 +/- 3 days (range 3-22). No patients died after the operation. Postoperative complications included extra-peritoneal extravasation (2), recurrent urinary tract infection (5) and urethral stricture (1). Symptom scores before and after the operation were 9 +/- 2 (range 4-14) and 8 +/- 3 (range 1-14) points respectively. The overall outcome of the procedure was satisfactory in only eight (16%) patients. The mean duration of symptomatic relief was 17 weeks (range 3-53). There was no significant difference between urodynamic results before and after the operation. Bladder instability observed in all patients before operating was demonstrated in 93% of patients after the operation.

CONCLUSION

The results of our study suggests that endoscopic bladder transection produces only a transient symptomatic relief in a few of those patients who have failed to respond to pharmacological manipulations. We do not feel that its continued role is justified.

Urinary symptoms: prevalence and severity in British men aged 55 and over

OBJECTIVE

To measure the prevalence and severity of urinary symptoms among men aged 55 and over in the British population.

DESIGN

Cross sectional population survey using a postal questionnaire.

SETTING

North West Thames health region.

SUBJECTS

1480 men aged 55 years and over randomly selected from 8 general practices.

MAIN OUTCOME MEASURES

Self reported frequency and severity of urinary symptoms, their bothersomeness and previous prostate surgery.

RESULTS

The response rate among eligible subjects was 78%. The prevalence of moderate and severe symptoms was 204 per 1000, rising from 160 per 1000 in the 55-59 age group to 259 per 1000 in the 70-74 age group and declining after the age of 80 to 119 per thousand in the 85+ age group. Twelve per cent of men reported previous prostate surgery, and the probability of having had surgery increases steadily with age. About a third of those undergoing surgery have recurrence or persistence of symptoms after surgery. Of men with moderate and severe symptoms, 27.9% reported that their symptoms were a medium or big problem, 36.9% reported that their symptoms interfered with their daily activities at least some of the time, and 43.1% were unhappy or 'felt terrible' about the prospect of a future with their current symptoms.

CONCLUSION

The prevalence of urinary symptoms in men is lower than previously reported, although there is a substantial number of men who are bothered by, or who find their lives adversely effected by them.

Update evaluation of benign prostatic hyperplasia: when should we offer prostatectomy?

OBJECTIVE

To investigate correlations between traditional and urodynamic criteria in the evaluation of prostatism and to try to establish an update evaluation of patients with benign prostatic hyperplasia (BPH) with the aim of preventing unnecessary prostatectomies.

PATIENTS AND METHODS

The series constituted 96 patients aged 43-86 years (mean 63.41 +/- 9.25) with prostatism and BPH. All were assessed by symptom analysis, digital rectal examination, residual urine determination, uroflowmetry and further multichannel urodynamic testing (medium fill cystometry, pressure flow study).

RESULTS

Residual urine determination was not a reliable criterion for selection of patients for surgery. A striking statistically significant correlation was evident when symptomatology and the results from multichannel urodynamic study were compared. No correlation was found between irritative symptoms and detrusor instability.

CONCLUSION

A significant proportion (23%) of the whole patient population was classified as a urodynamically unobstructed group to which we think prostatectomy should not be offered. We recommend that a pressure-flow study is performed in all patients with BPH with dominant irritative symptoms to identify those who are unobstructed.

Evaluation and results of treatments for prostatism

Men with symptoms of prostatism form a heterogenous group. The best treatment of proven obstruction or retention in fit men remains transurethral prostatectomy (TURP). Men presenting with symptoms of prostatism may have bladder outflow obstruction, detrusor instability or weak bladder contraction leading to low pressure/low flow voiding so it is perhaps not surprising that only 75% of men selected for TURP purely on the basis of symptoms have a good outcome. Pressure flow studies are the only precise method of diagnosing outflow obstruction. The problem of accurately diagnosing obstruction before treatment is started applies particularly to trials of new treatments such as lasers, high energy focused ultrasound and drugs. Laser treatment is producing short term results that are slightly inferior to TURP but may have less morbidity. The role of conservative treatment is important in selected men. Men who have severe intercurrent illness may be treated by means of intra-prostatic stents. In order to accurately assess a new treatment it is necessary to determine the short-term mortality, the morbidity, complication rate and outcome as well as the cost-effectiveness, long-term outcome and patient preference. These conditions have not yet been met for any of the new treatments for prostatism.

Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia

In previous studies the severity of symptoms of prostatism in men with benign prostatic hyperplasia have not correlated well with prostate size, degree of bladder trabeculation, uroflowmetry or post-void residual volume. As part of a prospective cohort study of benign prostatic hyperplasia treatment effectiveness in 4 university-based urology practices, we correlated symptom severity and these commonly used measures of disease severity. Symptom severity was quantified using the American Urological Association symptom index. Analyses were based on 198 outpatients completing a standardized evaluation (84 of these men have completed 6 months of followup after treatment with prostatectomy, balloon dilation, terazosin or watchful waiting). At baseline, symptom severity was not correlated with uroflowmetry, post-void residual, prostate size and degree of bladder trabeculation. However, symptom severity was much more strongly related to overall health status than the other measures. Reduction in symptoms with treatment did correlate with improvements in uroflowmetry. This poor baseline correlation with symptoms may reflect unreliability in measurement of the physiological/anatomical variables. Alternatively, these parameters may be measuring different pathophysiological phenomena.

Urodynamic study of ileocystoplasty in the treatment of idiopathic detrusor instability

Enterocystoplasty is being used with increasing frequency in the treatment of patients with idiopathic detrusor instability. We have performed a prospective clinical and urodynamic study of this procedure in 11 patients using both conventional (CMG) and ambulatory monitoring techniques (AM). Nine of 11 patients were satisfied with the symptomatic outcome, but 7 relied on clean intermittent self-catheterisation (CISC) to achieve a good result. Urodynamic studies demonstrated a significant increase in residual urine volume from 48 +/- 72 ml before to 347 +/- 298 ml after operation, but there was only a small and statistically insignificant increase in cystometric capacity. Detrusor instability, present before operation in all patients, could still be demonstrated in over half of them after operation. However, a significant decrease in the severity of instability was found after operation as assessed by an increased volume at first unstable contraction. The bladder volume before operation at which the first unstable contraction occurred was smaller in those who still had persistent instability after enterocystoplasty compared with those in whom instability could not be identified after operation. These results suggest that all patients about to undergo ileocystoplasty should be trained in the use of CISC. In selected patients with idiopathic detrusor instability refractory to other treatment, this procedure can yield satisfactory results.

Voiding patterns in men evaluated by a questionnaire survey

A questionnaire on obstructive and irritative voiding symptoms was sent to 572 men aged between 20 and 79 years, selected at random from the National Register; 337 questionnaires were completed. None of the responders had consulted a doctor because of voiding symptoms. There was a significant increase in voiding symptoms and in the obstructive, irritative and total symptom scores between the sixth and seventh [corrected] decades, whereas the increases in the other decades were small. Only the prevalence of terminal dribbling was uniform. The prevalence of single obstructive and irritative voiding symptoms in men aged 60 to 79 years without subjective prostatism was the same as in patients admitted with prostatism, although most of the men had milder symptoms. Only nocturia and urge incontinence were more prevalent in patients admitted with prostatism. About 20% of men in the oldest decades had symptoms equal in severity to those found in men undergoing prostatectomy; 29% and 11% of men in the eighth decade [corrected] had nocturia twice and 3 times or more respectively; 19% complained of urge incontinence. More information on possible treatment is needed.

Obstructive uropathy in patients with benign prostatic hyperplasia

In an attempt to determine the role of obstructive prostatic hyperplasia as a cause of irreversible renal function the records of 32 men with a diagnosis of benign prostatic hyperplasia and renal failure were reviewed. Patients were classified as either having a serum creatinine of more than or less than 4 mg.per 100 ml. when they were discharged from the hospital. Admission serum creatinine levels were comparable in both groups. Characteristics of the group with permanently impaired renal function included a longer mean duration of symptoms, higher incidence of urinary tract infection, lower average volume of residual urine and greater incidence of small kidneys with increased parenchymal echogenicity. These data assist in the objective prediction of patients who will have irreversible renal dysfunction when presenting with obstructive benign prostatic hyperplasia.

Relationship between detrusor function and residual urine in men undergoing prostatectomy

Two hundred and fifty-three men undergoing prostatectomy were studied by means of urodynamic investigation to determine the relationship between the volume of residual urine and detrusor function. Increased volumes of residual urine were associated significantly with increasing age, low peak flow rate and high urethral resistance. However, weak voiding pressures were uncommon and did not correlate with increased residual volumes. Increased residual volumes also correlated significantly with a high resting detrusor pressure and a high detrusor pressure rise during the filling phase, but there was a wide scatter of the results for pressure rise and patients could not be classified into groups on the basis of this parameter. Whilst detrusor decompensation was not manifest by weak voiding pressures in patients with increased residual volumes, impairment of the ability of the detrusor to empty the infused cystometric capacity during the subsequent voiding study correlated with increased residual volumes. These data are consistent with theories relating bladder outflow obstruction to the development of increased volumes of residual urine in men undergoing prostatectomy.