The significance of bladder trabeculation in the female lower urinary system: an objective evaluation by urodynamic studies

A grading system for evaluation of bladder trabeculation

PURPOSE

To establish a parameter-based grading system for evaluating bladder trabeculation (BT).

MATERIALS AND METHODS

A retrospective analysis was conducted on children diagnosed with posterior urethral valve (PUV) or neurogenic bladder (NB) who underwent voiding cystourethrogram (VCUG), urodynamic testing, and urological ultrasonography between January 2016 and October 2022. Cases involving urologic surgery, secondary bladder pathology, and an interval of more than 12 months between examinations were excluded. A parameter named Bladder Dispersion (BD) was calculated through fluoroscopic images, and the grading system was developed as follows: BD < 40 (Grade 0), 40 ≤ BD < 60 (Grade 1), 60 ≤ BD < 90 (Grade 2), BD ≥ 90 (Grade 3). Grades 0-1 were classified as low-risk group, while grades 2-3 were classified as high-risk group. Analysis of variance, Kruskal-Wallis test, and Chi-square test were performed to compare urodynamic results and complications across different grades and groups.

RESULTS

A total of 74 patients were eligible to participate, which included 46 boys (62.2%) and 28 girls (37.8%), the mean age was 75.18 ± 48.39 months. Among them, 11 (14.9%) were PUV, 50 (67.6%) were NB, and 13 (17.5%) were PUV and NB. Significant differences were observed in maximum detrusor pressure, post-void residual urine ratio, and compliance among grades 0-3. Severe hydronephrosis and histories of urinary tract infection were more prevalent in the high-risk group.

CONCLUSION

A reliable grading system with objective standards was proposed which could aid in the assessment of BT severity.

Voiding dynamics of pelvic organ prolapse: Large scale comparative study

PURPOSE

To determine the voiding dynamics of the patients with pelvic organ prolapse (POP).

MATERIALS AND METHODS

A retrospective patient file review was performed of 877 female patients with lower urinary tract symptoms. After exclusion criteria 373 female patients were eligible for the study. Two patient groups w/wo prolapse were identified. The symptoms, patient characteristics, patterns of free urine flow, and detrusor voiding pressure curves were compared between two groups. A comparison of the urodynamic findings between the subgroups (mild/moderate, severe, and w/o prolapse) was made and shown on a scatter plot graphics of P_det Q_max versus Q_max as well.

RESULTS

A total of 373 patients with median age 54 (18-92), 189 (51%) had varying degrees and forms of POP while 184 (49%) did not have any prolapse (p < 0.003). Logistic regression analysis results showed that older age [p = 0.023, odds ratio (OR) = 1.01, confidence interval (CI): (1.00-1.03)], weaker pelvic floor muscle strength [p = 0.032, OR = 1.67, CI: (1.04-2.69)], more frequent symptom of hesitancy [p = 0.003 OR = 2.15 CI: (1.29-3.58)], prolonged-tailed shaped curve pattern of free urine flow [p = 0.027 OR = 1.97 CI: (1.08-3.58)], and higher P_det Q_max (22 cmH₂ O) values [p = 0.002, OR = 1.02, CI: (1.00-1.03)] were the independent different features of the patients with prolapse. Subgroup urodynamic analysis showed significantly lower free flowmetry Q_max and higher P_det Q_max values in patients with severe prolapse. Prolonged/tailed-shaped curve pattern of free urine flow was significantly more frequent in patients with prolapse.

CONCLUSIONS

Voiding dynamics of the patients with prolapse were significantly different from the patients' w/o prolapse. They had higher P_det Q_max values, more frequent symptom of hesitancy, and prolonged shaped free flow curve pattern. Free flow Q_max values were lower in patients with severe prolapse.

Association of bladder trabeculation and neurogenic bladder with spinal cord injury

OBJECTIVE

To compare clinical findings and urodynamic parameters according to trabeculation grade and analyze their correlations with trabeculation severity in neurogenic bladder caused by suprasacral spinal cord injury (SCI).

METHODS

A retrospective chart review was performed of neurogenic bladder caused by SCI. Bladder trabeculation grade was compared with SCI-related clinical parameters and bladder-related urodynamic parameters.

RESULTS

In SCI patients, factors such as disease duration, bladder capacity, detrusor pressure, peak detrusor pressure values, and compliance were significantly different between different grades of bladder trabeculation, while neurological level of injury, completeness, and detrusor sphincter dyssynergia had no clear relationship with bladder trabeculation grade. In the correlation analysis, vesicoureteral reflux was moderately correlated with trabeculation grade (correlation coefficient 0.433), while the correlation coefficients of disease duration, involuntary detrusor contraction, and bladder filling volume were between 0.3 and 0.4.

CONCLUSION

Bladder trabeculation with suprasacral-type neurogenic bladder was graded. Although disease duration was positively correlated with bladder trabeculation grade, differences in the neurological level of injury or American Spinal Injury Association Impairment Scale score were not observed. Bladder volume, peak detrusor pressure, compliance, reflex volume, and vesicoureteral reflux also showed significant differences according to trabeculation grade. Vesicoureteral reflux was moderately correlated with trabeculation grade.

Irreversible Bladder Remodeling Induced by Fibrosis

Underactive bladder and impaired bladder compliance are irreversible problems associated with bladder fibrosis. Remodeling of the extracellular matrix is regarded as an important mechanism associated with bladder fibrosis. However, various risk factors and conditions contribute to the functional impairment of the bladder associated with fibrosis, and there is limited knowledge about bladder fibrosis-associated problems in the field of neurourology. Further studies are thus necessary to elucidate the underlying mechanism of bladder fibrosis and to identify effective treatment.

Bladder diverticuli following injection of onabotulinum toxin A in a patient with multiple sclerosis and autosomal dominant polycystic kidney disease

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Bladder diverticuli identified following Botox treatment of neurogenic bladder.

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Magnetic resonance imaging is useful to detect bladder diverticuli following Botox injections.

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Magnetic resonance imaging following Botox treatment of neurogenic bladder may be helpful.

Urinary incontinence due to neurogenic detrusor overactivity is common in patients with disorders of lower motor neurons controlling the bladder. Multiple sclerosis is a major cause of neurogenic detrusor overactivity, which negatively impacts quality of life. Bladder wall injection of onabotulinum toxin A can diminish spontaneous bladder contraction, urinary urgency, and urge incontinence. Herein we report a 61-year-old woman with multiple sclerosis and autosomal dominant polycystic kidney disease with bladder trabeculation developing after repeated injections of onabotulinum toxin A.

Establishment of the novel cystoscopic classification for bladder trabeculation of neurogenic bladder

OBJECTIVE

To establish a cystoscopic grading system for trabeculation of neurogenic bladders.

MATERIALS AND METHODS

A total of 140 neurogenic bladder patients who had undergone both fluoroscopic urodynamic study and cystoscopic examination were retrospectively reviewed. Cystoscopic images were categorized into 4 grades according to the formation of the muscle bundle layer and height-to-width ratio of the muscle bundle: 0 (none), 1 (mild), 2 (moderate), and 3 (severe). Test-retest reliability and interobserver reliability were assessed. Cystoscopic grade of the trabeculated bladder was correlated with urodynamic results and the fluoroscopic grades of trabeculation.

RESULTS

The test-retest reliability showed almost perfect agreement with all levels of Cronbach alpha ranging from 0.925 to 0.970. The intraclass correlation coefficient was 0.986, indicative of an almost perfect level of interobserver reliability. The grading system showed clinical significance by correlation with urodynamic parameters (Qmax, P value = .016; postvoid residual, P value <.001; bladder outlet obstruction index, P value = .002). Cystoscopic grades correlated moderately well with fluoroscopic grades, showing comparable clinical significance with fluoroscopic grades.

CONCLUSION

Our results showed that this novel cystoscopic classification of bladder trabeculation was highly reliable.

The significance and factors related to bladder outlet obstruction in pelvic floor dysfunction in preoperative urodynamic studies: A retrospective cohort study

Objective

To demonstrate the significance of bladder outlet obstruction (BOO) in preoperative urodynamic studies (UDS) in women who have been diagnosed with pelvic floor dysfunction including pelvic organ prolapsed (POP) and stress urinary incontinence (SUI).

Methods

The medical records of 150 patients with pelvic floor dysfunction who underwent preoperative UDS at Yonsei University Health System from 2006 to 2012 were reviewed. Under the criteria of BOO, as a maximal flow rate in free-flow study (Q_max) less than 12 mL/sec and a detrusor pressure at Q_max in pressure-flow study (P_detQ_max) higher than 20 cmH₂O in UDS, they were divided into two groups: a group of 50 patients with BOO and a group of 100 patients without BOO. Comparisons were made between the patients with and without BOO in preoperative UDS.

Results

In the POP-with-SUI group, 25 patients with BOO had lower mean Q_max (10.0 vs. 25.4 mL/sec, P < 0.001), higher P_detQ_max (49.6 vs. 21.5 cmH₂O, P < 0.001), lower maximum cystometric capacity (422.7 vs. 454.0 mL, P = 0.007), and higher postvoidal residual volume (44.3 vs. 21.1 mL, P = 0.021) than the patients without BOO. In the SUI-only group, the mean Q_max was significantly lower in the 25 patients with BOO (9.4 vs. 25.4 mL/sec, P < 0.001). The mean P_detQ_max was significantly higher with BOO (39.6 vs. 25.4 cmH₂O, P = 0.004). In the univariate analyses, menopause, maximum cystometric capacity, and cystoscopic bladder trabeculation were associated with BOO.

Conclusion

In the univariate analysis, menopause, MCC and cystoscopic bladder trabeculation were associated with BOO. In the multivariate model, however, no significant association with BOO was found.

Establishment of a grading system for bladder trabeculation

OBJECTIVE

To establish a grading system for bladder trabeculation.

METHODS

A total of 228 patients who underwent videourodynamic studies were retrospectively reviewed. All fluoroscopic images included were gathered and were classified into 4 grades of trabeculation according to maximum depth and portion of bladder surface occupied: 0 (none), 1 (mild, depth <5 mm and area <1/2 of bladder), 2 (moderate, depth 5-10 mm and area ≥ 1/2 of bladder), and 3 (severe, depth >10 mm and area ≥ 1/2 of bladder). Presence of vesicoureteral refluxes, urethral leaks, and diverticula were evaluated. Grades were determined by 9 participants, and test-retest reliability was assessed over the span of 2 weeks. To evaluate interobserver and test-retest reliabilities, the intraclass correlation coefficient, Crohn's kappa, and Spearman's correlation coefficient were analyzed.

RESULTS

We found the mean trabeculation depths to be 6.5 ± 6.1 mm and with increasing trabeculation grade, refluxes, and urethral leaks increased. The number of diverticula, however, was unrelated to the grade. The interobserver reliability was almost perfect, with the intraclass correlation coefficients of 0.985 in fluoroscopy. Test-retest reliability was strong between repeated grading, and all values of Crohn's kappa showed almost perfect agreement (from 0.870 to 0.955). Urodynamic results of free uroflowmetry and voiding cystometry showed clinical significance of this trabeculation classification grade.

CONCLUSION

Interobserver and test-retest reliabilities proved the reliability and validity of the grading system for bladder trabeculation using trabeculation depths and area covering the bladder surface.

Pelvic organ prolapse and overactive bladder

AIMS

In this review we try to shed light on the following questions: *How frequently are symptoms of overactive bladder (OAB) and is detrusor overactivity (DO) present in patients with pelvic organ prolapse (POP) and is there a difference from women without POP? *Does the presence of OAB symptoms depend on the prolapsed compartment and/or stage of the prolapse? *What is the possible pathophysiology of OAB in POP? *Do OAB symptoms and DO change after conservative or surgical treatment of POP?

METHODS

We searched on Medline and Embase for relevant studies. We only included studies in which actual data about OAB symptoms were available. All data for prolapse surgery were without the results of concomitant stress urinary incontinence (SUI) surgery.

RESULTS

Community- and hospital-based studies showed that the prevalence of OAB symptoms was greater in patients with POP than without POP. No evidence was found for a relationship between the compartment or stage of the prolapse and the presence of OAB symptoms. All treatments for POP (surgery, pessaries) resulted in an improvement in OAB symptoms. It is unclear what predicts whether OAB symptoms disappear or not. When there is concomitant DO and POP, following POP surgery DO disappear in a proportion of the patients. Bladder outlet obstruction is likely to be the most important mechanism by which POP induces OAB symptoms and DO signs. However, several other mechanisms might also play a role.

CONCLUSIONS

There are strong indications that there is a causal relationship between OAB and POP.

Clinical significance of intravesical prostatic protrusion in patients with benign prostatic enlargement

OBJECTIVES

We evaluated a noninvasive method to predict bladder outlet obstruction (BOO) and bladder function in patients with benign prostatic enlargement (BPE) based on intravesical prostatic protrusion (IPP) using transabdominal ultrasound.

METHODS

The records of 206 first-visit patients with BPE were reviewed. We divided patients into two groups based on the degree of IPP: the significant IPP group (greater than 10 mm) and the no significant IPP group (10 mm or less). We analyzed clinical data and urodynamic findings of the two groups to define the clinical significance of IPP.

RESULTS

In the clinical data, increased prostate volume, serum prostate specific antigen, postvoiding residual urine volume (PVR), incidence of acute urine residual (AUR), and bladder trabeculation appeared more often in the significant IPP group (P <0.05). Positive correlation was found between IPP and prostate volume as well as PVR (Spearman's rho = 0.401 and 0.342, respectively). In the urodynamic findings, significantly lower peak flow rate (Qmax) and higher incidence of detrusor overactivity and low bladder compliance both existed in the significant IPP group (P <0.0l). In addition, maximum detrusor pressure (Pdet.max) and BOO index (BOOI) were significantly higher in the significant IPP group (P <0.05). The correlation coefficient (Spearman's rho) between IPP and Qmax, Pdet.max, and BOOI was -0.284, 0.252, and 0.456, respectively.

CONCLUSIONS

Intravesical prostatic protrusion is a useful predictor for evaluating BOO and detrusor function. BOO and impaired detrusor function in significant IPP patients are more severe. The significant IPP patients, especially those presenting with AUR, may benefit from early surgical intervention.

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.