Ultrasound measurement of bladder wall thickness in different forms of detrusor overactivity

Introduction and hypothesis  

Aims of this study were to compare the ultrasound measurement of bladder wall thickness (BWT) in women with different urodynamic diagnosis and to correlate BWT to the different urodynamic findings of detrusor overactivity (DO).     

Clinical usefulness of ultrasound assessment of detrusor wall thickness in patients with neurogenic lower urinary tract dysfunction due to spinal cord injury: urodynamics made easy?

Purpose

To evaluate the clinical usefulness of sonographic measurement of detrusor wall thickness (DWT) for the prediction of risk factors in patients with neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI).

Methods

In a prospective study, 60 consecutive patients with NLUTD due to SCI presenting for routine urodynamic assessment at a specialized SCI center underwent additional measurement of DWT at varying bladder volumes. Results of urodynamic testing were classified into favorable and unfavorable. DWT at maximum capacity was used to calculate a possible cutoff value for favorable urodynamic results.

Results

Urodynamic results were favorable in 48 patients and unfavorable in 12 patients. A DWT of 0.97 mm or less can safely (sensitivity 91.7 %, specificity 63.0 %) be used as a cutoff point for the absence of risk factors for renal damage.

Conclusion

According to our results, DWT may be useful as an additional risk assessment for renal damage in patients with NLUTD due to SCI. However, as other parameters required for bladder management, especially detrusor overactivity, cannot be evaluated by this technique, it cannot replace urodynamic testing.     

Transvaginal ultrasound measurement of bladder wall thickness: a more reliable approach than transperineal and transabdominal approaches

Study Type – Diagnosis (exploratory cohort)
Level of Evidence 2b OBJECTIVES To validate transperineal, transabdominal and transvaginal ultrasound (US) techniques to measure bladder wall thickness (BWT). SUBJECTS AND METHODS Women underwent US measurement of BWT at three different anatomical sites: anterior wall, dome and trigone of the bladder by two ‘blinded’ operators using transabdominal, transperineal and transvaginal approaches at separate visits and by a single operator using transabdominal and transperineal techniques. Bland–Altman analysis was used to determine interobserver reliability for all three techniques and intraobserver reliability for transabdominal and transperineal methods. RESULTS In all, 25 women were scanned. The transperineal US had a high interobserver mean difference when measuring the anterior BWT (?0.34) and a high intraobserver mean difference when measuring the anterior (0.54) and dome BWT (0.33). Transabdominal US had a high interobserver mean difference for all measurements of BWT, and a high intraobserver mean difference when measuring the trigonal thickness (0.56). Transvaginal US had a consistent interobserver mean difference for all three measurements. The transperineal and transabominal approaches had the widest intraobserver and interobserver 95% confidence intervals of the mean difference when compared with the transvaginal approach. CONCLUSIONS Transabdominal and transperineal US for measuring BWT did not have good intraobserver and interobserver reliability for measurement of the three anatomical sites to determine mean BWT. Transvaginal US had good interobserver reliability, thus mean BWT is best measured using the transvaginal approach.     

Transabdominal ultrasonography of detrusor wall thickness in women with overactive bladder

Study Type – Diagnostic (case series)
Level of Evidence 4

OBJECTIVE

To determine the clinical usefulness of measuring detrusor wall thickness (DWT) as a noninvasive test in women with overactive bladder (OAB).

PATIENTS, SUBJECTS AND METHODS

We prospectively enrolled 122 women with dry OAB, wet OAB, and women with no OAB symptoms (control group). A 3‐day voiding diary was used to differentiate between wet and dry OAB. Transabdominal ultrasonography (TAUS) measurements of DWT were taken at bladder volumes of 250–300 mL and the maximal bladder capacity by both catheter‐ and natural‐filling. Video‐urodynamic studies (VUDS) were used to classify bladder dysfunction in 88 of the women.

RESULTS

The mean (range) age of the women was 58 (20–94) years. There were 39 ‘normal’ controls, 44 women had dry OAB, and 39 had wet OAB. Of the 88 women who had VUDS, 28 had a ‘normal’ test, 30 had increased bladder sensation (IBS), and 30 had detrusor overactivity (DO). The mean DWT at 250–300 mL among three symptomatic subgroups or urodynamic subgroups showed no significant difference by either catheter‐ or natural‐filling methods. The women with wet OAB had significantly greater DWTs than the controls at maximal bladder volume. The maximal bladder capacity was significantly greater in ‘normal’ women than in those with OAB. If we corrected maximal bladder volume to 250 mL, DWT at corrected 250 mL showed no significant difference among three symptomatic subgroups.

CONCLUSIONS

DWT measured by TAUS in women with OAB and without OAB was not different and did not differ with urodynamic status. Thus, TAUS measurement of DWT is not recommended as a useful diagnostic test for DO in women with OAB.     

Clinical and urodynamic differences among women with overactive bladder according to the presence of detrusor overactivity

Introduction and hypothesis

We tried to determine whether clinical and urodynamic differences exist between women with and without detrusor overactivity (DO) using a large database of overactive bladder (OAB) patients.

Methods

We reviewed the medical records of 513 women who underwent urodynamic studies for OAB symptoms without neurogenic or anatomical conditions that affect micturition function. Clinical symptoms were evaluated using a 3-day frequency-volume chart (FVC) including the Urinary Sensation Scale and American Urological Association Symptom Index (AUA-SI). All clinical and urodynamic findings were compared between women with and without DO.

Results

The patients’ mean age was 58.9 years. DO was identified urodynamically in 167 (32.6 %) women. Those with DO were older (62.9 vs 57.0 years, p?<?0.001); however, no differences in AUA-SI, episodes of daytime voiding, and episodes of nocturia were observed between the groups. Functional bladder capacity was smaller in women with DO; however, this difference did not reach statistical significance. Women with DO had significantly more urgency incontinence symptoms than those without DO (55.1 vs 29.5 %, p?<?0.001). In urodynamic parameters, the volumes at first desire to void and strong desire to void and maximum cystometric capacity were significantly smaller, and detrusor pressure at the opening was significantly higher in women with DO compared to subjects without DO (26.2 vs 21.2 cmH₂O, p?=?0.004).

Conclusions

Our findings suggest a more severe disturbance of bladder function when DO exists, although no differences were observed in symptom scores and 3-day FVC parameters among women with OAB symptoms according to the presence of DO.     

Correlation of bladder wall thickness and treatment success in types of urinary incontinence

Introduction and hypothesis

The aim of the study was to investigate the correlation between mean bladder wall thickness (BWT) and treatment success in patients diagnosed with urinary incontinence, based on urodynamic test results.

Methods

In this prospective study, patient urinary incontinence type was identified using urodynamic tests. Patients (N?=?125) were categorized into three groups: urodynamic stress incontinence (SUI), detrusor over-activity (DO) and mixed urinary incontinence. Measurements from the bladder dome, anterior wall and trigone were averaged to calculate BWT. Student’s t test and Mann–Whitney U test were used to compare pre-treatment BWT. Receiver operating characteristic (ROC) curve analysis was used to determine optimal cut-off values for BWT to predict treatment success.

Results

Mean pre-treatment BWT significantly differed between success and non-success groups for each urinary incontinence type (p value for the SUI, DO and MUI groups was 0.043, 0.001 and 0.002 respectively). Using ROC curves to anticipate the treatment success, a threshold was calculated for mean pre-treatment BWT; 5.05 mm for SUI (sensitivity 74 %, specificity 66 %, positive predictive value [PPV] 85 %, negative predictive value [NPV] 50 %), 4.98 mm for DO (sensitivity 73 %, specificity 92 %, PPV 95 %, NPV 63 %) and 5.31 mm for mixed type (sensitivity 88 %, specificity 73 %, PPV 79 %, NPV 85 %).

Conclusions

The study results suggest a significant relationship between the pre-treatment BWT and the success of urinary incontinence treatment. The mean BWT may be used as a benchmark in assessing the responsiveness to treatment of urinary incontinence types.

     

The role of invasive and non-invasive urodynamics in male voiding lower urinary tract symptoms

Introduction

Troublesome voiding lower urinary tract symptoms (LUTS) are a common problem in men, particularly with ageing. Implicitly, management of voiding LUTS can be guided by accurate determination of underlying mechanisms, distinguishing men with voiding symptoms caused by outlet obstruction from those with reduced bladder contractility.

Methods

A PubMed search of the published literature on invasive and non-invasive methods used to assess lower urinary tract function was carried out.

Results

A multitude of methods have been applied to assess LUTS. Multichannel pressure flow studies (PFS) are the standard for diagnosing bladder outlet obstruction and underlying mechanisms of LUTS, though their invasive nature can be difficult to tolerate, and improved prediction of treatment outcome is disputed. Uroflowmetry and post void residual measurement are insufficient to make a definitive diagnosis. Ultrasound-derived measurements of bladder wall thickness and estimated bladder weight offer a potential non-invasive alternative to PFS, but their diagnostic parameters are still under evaluation. Non-invasive methods that measure isovolumetric bladder pressure by interrupting the urinary stream can reproducibly measure pressure and urinary flow, but are unable to determine the effects of abdominal straining during voiding and give no insight into urine storage symptoms. Doppler ultrasound during urethral flow is informative, but it is an expensive approach whose clinical utility has yet to be established.

Conclusion

A variety of non-invasive urodynamic and non-urodynamic techniques have been used to evaluate LUTS and some show great promise. However, there is as yet, insufficient evidence to justify replacement of invasive voiding cystometry by these investigational approaches.     

Which clinical risk factors determine a pathological urodynamic evaluation in patients with multiple sclerosis? an analysis of 100 prospective cases

Background

Urinary tract symptoms are an underestimated problem in multiple sclerosis (MS).

Objective

Hundred urodynamics of MS patients have been evaluated prospectively.

Design, setting and participants

In an inpatient rehabilitation, all persons with MS who also suffered from urinary tract symptoms received a voiding diary, post-void sonography and an urodynamic examination according to International Continence-Society-Standard.

Results and limitations

Between 10/2009 and 3/2011, 100 patients (79 women; 21 men; mean EDSS, 4.52 ± 2.26) were examined who had primary progressive MS (9×), relapsing–remitting MS (41×), secondary progressive MS (43×) and CIS (1×). The mean duration of MS was 10.26 ± 10.09 years and mean duration of LUTS, 6.9 ± 7.75 years. Urodynamic testing showed normal findings in 22 patients, detrusor overactivity in 7, increased bladder sensation without detrusor overactivity in 21, detrusor–sphincter dyssynergia in 26, detrusor hypocontractility in 12, detrusor acontractility in 4 and unclear diagnosis in 8 patients. Statistically significant risk factors for pathological urodynamic findings were as follows: wheelchair dependency, use of more than one incontinence pad per day and a MS type other than relapsing–remitting.

Conclusions

The urodynamic investigation at hand showed urinary tract dysfunction in 78 of 100 MS patients with lower urinary tract symptoms (LUTS). The long latency between the occurrence of MS and/or the beginning of LUTS and the first neuro-urological evaluation indicates a deficit in treatment. Beyond national guidelines, all MS patients should at regular intervals be questioned about LUTS and receive urodynamic assessment especially according to the presented risk profile.     

Is the beneficial effect of antimuscarinics related to motor or sensory changes in the bladder?

Introduction and hypothesis  

The aim of the study was to assess the sensory and motor effects of antimuscarinic treatment on the bladder in women with overactive bladder, detrusor overactivity demonstrated on urodynamics and a mean bladder wall thickness (BWT) greater than 5 mm.     

Improving the clinical prediction of detrusor overactivity by utilizing additional symptoms and signs to overactive bladder symptoms alone

Introduction and hypothesis

We attempted to improve the accuracy of the clinical diagnosis of detrusor overactivity (DO) by using other significant clinical parameters in addition to overactive bladder (OAB) symptoms alone.

Methods

One thousand one hundred and forty women attending for their initial urogynecological assessment, including urodynamics, due to symptoms of pelvic floor dysfunction, underwent a comprehensive clinical and urodynamic assessment. Multivariate logistic regression analysis of a wide range of clinical parameters was used in order to determine a model of factors most accurately predicting the urodynamic diagnosis of DO. Data were separated according to women without DO; women with DO. The analysis involved the stepwise building of an optimal clinical model for predicting DO.

Results

In multivariate analysis, the OAB symptoms of urgency incontinence, urgency and nocturia (not frequency) were significantly associated with DO. Their prediction of DO was not particularly accurate (sensitivity 0.64; specificity 0.67). The addition of other significant clinical parameter, i.e. absent symptoms of stress incontinence; lower parity (0–1); no signs of prolapse, to the diagnostic model, resulted in marginally improved accuracy (area under the ROC curve increased from 0.70 to 0.74).

Conclusions

Overactive bladder symptoms alone are not accurate in predicting DO. Adding other significant clinical parameters to the model resulted in a small statistical advantage, which is not clinically useful. An accurate clinical diagnosis of DO in women would appear to remain elusive.     

Systematic review of the accuracy of ultrasound as the method of measuring bladder wall thickness in the diagnosis of detrusor overactivity

Introduction and hypothesis  

A systematic review was carried out to study the hypothesis that bladder wall thickness (BWT) on ultrasound is accurate in diagnosing detrusor overactivity (DO).     

How often does detrusor overactivity cause urinary leakage during a stress test in women with mixed urinary incontinence?

Introduction and hypothesis

The study examined how often detrusor overactivity (DO) causes leakage during a stress test in women with mixed urinary incontinence (MUI) and whether there are differences between those who do and those who do not have DO during the stress test.

Methods

A retrospective study was performed in 100 women who had an ambulatory urodynamic recording done where bladder, urethral, and vaginal pressures, and leakage were recorded. The stress test consisted of 20 jumping jacks and three forceful coughs.

Results

All the women leaked during the stress test: five due to simultaneous stress test and DO, 87 due to the stress test only, and eight during the stress test as well as due to DO before or after the stress test.

Conclusions

During the stress test, 5 % of women with MUI leaked due to the coughs and jumps and simultaneous DO. Women in whom DO was detected had significantly higher Urgency Incontinence Index and leakage during the 24-h pad test.     

Ultrasound detrusor wall thickness measurement in combination with bladder capacity can safely detect detrusor underactivity in adult men

Purpose

Detrusor underactivity (DU) has lately gained increasing interest because this bladder condition is an important cause of post-void residual urine and lower urinary tract symptoms (LUTS) in adult men. Until now, DU can only be diagnosed by pressure–flow measurement. Therefore, the aim of this study was to search for noninvasive tests which can safely predict DU in adult men.

Methods

Unselected, treatment-naïve male patients aged ≥40 years with uncomplicated, non-neurogenic LUTS were prospectively evaluated. All men received—after standard assessment of male LUTS–ultrasound detrusor wall thickness (DWT) measurements at a bladder filling ≥250 ml and computer urodynamic investigation. DU was defined as incomplete bladder emptying (>30 ml) in the absence of bladder outlet obstruction or dysfunctional voiding. Classification and regression tree (CART) analysis was used to determine parameters and threshold values for DU.

Results

The study population consisted of 143 consecutive men with medians of 62 years, IPSS 16, and prostate volume 35 ml. In total, 33 patients (23.1 %) had DU. CART analysis showed that all men with DWT ≤ 1.23 mm plus bladder capacity >445 ml had DU. This multivariate model has a sensitivity of 42 %, specificity of 100 %, positive predictive value of 100 %, and negative predictive value of 85 %.

Conclusions

This study showed that all men with ultrasound DWT ≤ 1.23 mm + bladder capacity >445 ml have DU. Combination of these two tests could help physicians to diagnose DU noninvasively in clinical practice. A prospective independent study should confirm these results.

     

Der Stellenwert der intravesikalen Elektrostimulation in der Therapie der akuten prolongierten Blasenüberdehnung

Background

The effectiveness of intravesical electrostimulation (IVES) in the treatment of acute prolonged bladder overdistension (PBO) was investigated.

Methods

Sixteen patients (♀11, ♂5, ø54 years) after PBO (bladder filling volume: 1317±320 ml) were evaluated: 11 after surgery and 5 after polytrauma, psychosomatic disorder or LV4 fracture. After exclusion of a neurogenic aetiology and a urodynamic examination, IVES was performed besides IC or suprapubic catheter.

Results

Group 1: six patients with a weak detrusor (p_{detr. max.}<30 cmH₂O); group 2: ten patients had detrusor acontractility. After 25 IVES sessions, group 1 showed a significant increase of p_{detr. max.} (p=0.01) as well as a decrease in PVR (31% to 3% of bladder capacity, p=0.02). Group 2 had no significant increase of p_{detr. max}.

Conclusions

Two-thirds of patients with a weak detrusor after PBO will regain balanced voiding after IVES due to detrusor reinforcement. With an acontractile detrusor only bladder sensation improves.     

The prevalence of detrusor overactivity amongst patients with symptoms of overactive bladder: a retrospective cohort study

Introduction and hypothesis

Overactive bladder (OAB) is a symptom-based condition consisting of urgency, with or without incontinence, usually with frequency and nocturia. There are many potential causes of OAB, yet many patients are prescribed anticholinergic medications empirically. This study aimed to determine what proportion of patients presenting for urogynecologic assessment with symptoms of OAB had urodynamic detrusor overactivity (DO).

Methods

Retrospective chart review was performed for 220 consecutive patient referrals. Demographic data, physical exam information, and urodynamic results were collected. The t test and Fisher’s exact test were used for statistical analyses.

Results

The prevalence of DO was 11.8?% in this population. Urogenital atrophy and incomplete emptying were more common. Patients with DO were older and more often menopausal than those without DO. Significant prolapse was a common finding amongst patients with OAB symptoms.

Conclusions

Patients with symptoms of OAB should undergo pelvic examination and assessment of post-void residuals before being initiated on anticholinergic medication.     

Changes in nerve growth factor level and symptom severity following antibiotic treatment for refractory overactive bladder

Introduction and hypothesis

Overactive bladder (OAB) has a multifactorial aetiology, and for some women symptoms may be associated with chronic urothelial inflammation secondary to bacterial colonisation. One marker of such inflammation may be urinary nerve growth factor (NGF). We hypothesised that for women with OAB and urothelial inflammation, urinary NGF would be reduced following antibiotic therapy.

Methods

Women with overactive bladder and urodynamic diagnosis of detrusor overactivity who were refractory to anticholinergics, and had histological evidence of urothelial inflammation were treated with a 6-week course of rotating antibiotics. Urinary NGF was measured by ELISA before and after treatment. Three-day bladder diaries, the Patients’ Perception of Intensity of Urgency Scale, the King’s Health Questionnaire and the Patients’ Perception of Bladder Condition questionnaire were used to assess subjective and objective outcomes of therapy.

Results

Thirty-nine women with refractory DO were recruited. The NGF levels decreased significantly after antibiotic therapy (Wilcoxon signed rank test; p?=?0.015). There were significant improvements in daytime frequency, nocturia and urgency (p?<?0.05), and 74 % of women reported improvement in perception of their bladder condition.

Conclusions

Urinary NGF is responsive to antibiotic therapy. Women with refractory overactive bladder and elevated NGF may benefit from antibiotic treatment.     

Vesico-ureteral reflux in women with idiopathic high-pressure detrusor overactivity: prevalence,bladder function,and effect on the upper urinary tract

Introduction and hypothesis

To assess the prevalence of vesico-ureteral reflux (VUR) and upper urinary tract damage in women with idiopathic high-pressure detrusor overactivity (IHPDO) and to characterize their bladder function.

Methods

A retrospective chart review of women diagnosed with IHPDO (detrusor pressures > 40 cm H₂O during involuntary bladder contractions) from 2007 to 2010 was conducted. Women were assessed for VUR by X-ray voiding cysto-urethrogram. Renal ultrasound or CT urogram, serum BUN/creatinine, and urinalyses were performed if reflux reached the renal pelvices. Cystometric and voiding pressure study data were reviewed for detrusor overactivity pressure and volume, voiding dysfunction, urethral relaxation, compliance, and bladder outlet obstruction.

Results

Sixty-five women were diagnosed with IHPDO, and 50 completed an X-ray voiding cysto-urethrogram. The median (range) detrusor overactivity pressure was 65 (41–251) cm H₂O. Four (8.0 %) women had IHPDO; none had upper urinary tract deterioration. The majority of women exhibited urethral relaxation with voiding, impaired compliance, and bladder outlet obstruction.

Conclusions

Women with IHPDO are at risk of low-grade vesico-ureteral reflux. However, most women with IHPDO are likely protected from reflux by intermittent exposure to high detrusor pressures and the ability to decompress the bladder by urethral relaxation.     

A multicenter prospective trial evaluating fetal bovine dermal graft (Xenform® Matrix) for pelvic reconstructive surgery

Background

Most bladder tumors are derived from the urothelium. Benign mesenchymal tumors are rare. Leiomyoma of the bladder is the most common benign neoplasm. We present a case of leiomyoma of the bladder presenting with acute urinary retention in a female patient and report on the post-operative change in urodynamic findings. To our knowledge, few cases of this kind have been reported.

Case Presentation

A 56-year-old woman presented with acute urinary retention. Evaluations including ultrasound, magnetic resonance imaging, cystoscopy, and urodynamics contributed to a diagnosis of leiomyoma of the bladder. Various medications were ineffective for solving her lower urinary tract symptoms; therefore, a transurethral resection was performed. The final pathological report was leiomyoma. After the operation, her symptoms resolved; this improvement was confirmed by an urodynamic analysis. The postoperative urodynamics demonstrated a lower frequency of detrusor overactivity during filling cystometry and an increase in the uroflow rate, with reduced detrusor pressure in a pressure flow study.

Conclusions

Leiomyoma of the bladder can cause female outlet obstruction. A review of the literature and disease management is discussed.     

Ohrakupunktur bei Detrusorhyperaktivität

Background

Patients suffering from overactive bladder/detrusor overactivity (OAB/DO) seem to benefit from body acupuncture. The study was carried out to test if auricular acupuncture (AAP), which is supposed to show an immediate effect, can also cause urodynamic changes.

Patients and methods

The OAB/DO condition was verified by means of cystometry in 14 patients. These patients were subjected to bilateral AAP after cystometry, a second cystometry was performed 20-30 min later and data were analyzed using the Wilcoxon rank-sum test.

Results

None of the patients showed local or systemic complications but DO persisted in all patients and urge urinary incontinence (UUI) persisted in 85 % (11/13) of patients. Intravesical pressure decreased after AAP but without reaching statistical significance. In 22 % (2/9) of patients residual volume (RV) disappeared completely while 78 % (7/9) of patients showed significant reduction of RV.

Conclusions

This study could not prove a significant influence of AAP on DO or UUI; therefore an immediate effect of AAP in patients suffering from OAB/DO seems to be unlikely. Further studies are necessary to evaluate the effect of repeated AAP sessions on urodynamic changes.     

Measurement of detrusor wall thickness in women with overactive bladder by transvaginal and transabdominal sonography

Introduction and hypothesis  

Women with overactive bladder (OAB) might have a greater detrusor wall thickness (DWT) suggestive of detrusor overactivity (DO).