Voiding urgency and detrusor contractility in women with overactive bladders.

AIMS: To check whether the contractility of overactive bladders would be affected by voiding urgency. METHODS: We urodynamically studied 100 women: 20 normal controls (group 1), 60 patients with idiopathic detrusor overactivity (DO), and 20 with neurogenic DO from intracerebral lesions. The idiopathic DO groups 2A (n = 20), 2B (n = 20), and 3 (n = 20) had moderate, severe, and no voiding urgency, respectively. The neurogenic DO group 4 had severe urgency. The delay time of urgent void at cystometry (2 minutes or more or, respectively, less than 2 minutes) defined moderate or severe urgency. Detrusor contractility was defined by the maximum bladder external voiding power (WF(max)). RESULTS: WF(max) was higher in the idiopathic DO patients than in the controls, had the highest values in group 2B, and did not differ significantly between groups 1-4 and 2A-3. CONCLUSIONS: We inferred from our data that idiopathic DO suggests a facilitation of voiding contractions and that such facilitation might be centrally amplified by severe urgency. This amplifying effect would probably be impaired in cases of neurogenic DO from intracerebral lesions.     

Developing and validating a new nomogram for diagnosing bladder outlet obstruction in women

Objective

To develop and validate a nomogram for assessing bladder outlet obstruction (BOO) in women derived from concurrent P_det.Qmax and Q_max based on radiographic evidence of increased urethral resistance.

Patients and Methods

Retrospective analysis of prospectively acquired video‐urodynamics and clinical data of 185 women (development cohort) was performed. The P_det.Qmax were plotted against Q_max and cluster analysis was performed to determine an axis that best divided the definitively obstructed and unobstructed. Using data from a further 350 women (validation cohort), the sensitivity and specificity of the derived criterion was calculated. Finally, the data from both groups was pooled together and using binary logistic regression analysis, a nomogram was produced.

Results

Of the 535 patients in the two cohorts, (122 [22.8%]) demonstrated radiographic evidence of BOO. Cluster analysis identified the axis that best separates the radiographically obstructed and unobstructed as P_det.Qmax = 2*Q_max. Using the data from the validation cohort, the sensitivity and specificity for this was calculated as 0.94 and 0.93, respectively. A nomogram, representing the probability of BOO for concurrent P_det.Qmax and Q_max measurements was derived by pooling data from both cohorts. Alternatively, a female BOO index (BOOIf) may be calculated mathematically using the formula BOOIf = P_det.Qmax ? 2.2*Q_{max, that is,} BOOIf < 0, <10% probability of obstruction, BOOIf > 5 likely obstructed (50%) and If BOOIf > 18, obstruction almost certain (>90%).

Conclusion

A female BOO nomogram (the SG nomogram) with high sensitivity and specificity is proposed. The nomogram can be used to stratify the degree of BOO or assess response to treatment.     

Urgency degree and bladder contraction velocity: sequential changes in women with idiopathic detrusor overactivity

AIMS: In patients with idiopathic detrusor overactivity (DO) who showed storage symptoms worsening with time, we checked whether and which urodynamic parameter changes are associated with an increased urgency degree. MATERIALS AND METHODS: We analyzed retrospectively the urodynamic findings in 54 women -27 with storage symptoms (Group A, mean age 32 +/- 7 years) and 27 controls (Group B, mean age 30 +/- 9 years). These latter had a history of recurrent UTIs (urinary tract infections), but when seen by us had no UTI, DO, lower urinary tract symptoms, or any other pathological finding. Group A had a first urodynamic examination when first referred (time 1) and were re-assessed a mean of 16 months later (time 2) for worsened storage symptoms. RESULTS: In Group A, an idiopathic DO was shown at both times 1 and 2; urgency of voiding could be delayed during cystometry for >or=2 min (= moderate urgency) at time 1 and for <2 min (= severe urgency) at time 2; detrusor contraction strength or contractility proved higher than in Group B (P < 0.001) and increased from time 1 to time 2 (P < 0.001), detrusor shortening velocity being always the major component of the higher contractility levels. CONCLUSIONS: A DO-related increase in bladder contractility may have been further enhanced by severe urgency through a positive feedback mechanism. The urgency degree proved closely associated in DO patients with the level of detrusor shortening velocity rather than with detrusor pressure.     

Angiotensin II type 1 (AT-1) receptor inhibition partially prevents the urodynamic and detrusor changes associated with bladder outlet obstruction: a mouse model

Study Type – Therapy (case control) Level of Evidence 3b What's known on the subject? and What does the study add? Angiotensin II is the main effector peptide in the bladder local renin‐angiotensin system. This experiment demonstrates the role of this local renin‐angiotensin system with respect to bladder outlet obstruction.

OBJECTIVE

• ? To determine if treatment with an angiotensin II type 1 (AT‐1) receptor antagonist, losartan, can prevent the structural and functional changes that occur in a mouse model of bladder outlet obstruction (BOO).

MATERIALS AND METHODS

• ? Twenty‐four Balb/CAN mice underwent partial urethral obstruction for 6 weeks.
• ? Twelve mice were given oral losartan (10 mg/kg/day), and 12 were not. Six mice served as unobstructed controls, and six unobstructed mice were given oral losartan (10 mg/kg/day) to determine the effect of angiotensin II inhibition on the normal bladder.
• ? Bladder capacity (C), detrusor pressure during voiding (Pdet) and volume at first non‐voiding contraction (NVC1) as a percentage of C were recorded after 6 weeks.
• ? Bladders were stained with haematoxylin and eosin for measurement of detrusor muscular thickness, and graded as 1 = atrophy (<100 µm thick), 2 = normal (100–200 µm thick), 3 = hypertrophy (>200 µm thick) compared with controls.

RESULTS

• ? Compared with controls, BOO mice had greater C (153.5 ± 20.9 vs 57.5 ± 7.4 µl, P < 0.01), higher Pdet (28.8 ± 2.1 vs 12.1 ± 2.1 mm Hg), lower NVC1 (median = 24% vs 54% P= 0.03). BOO mice manifested greater bladder weight (93.2 ± 11.7 mg vs 26.8 ± 2.40 mg, P < 0.01) and greater detrusor muscle thickness (median 3 vs 2, P= 0.02).
• ? Compared with untreated BOO mice, mice treated with losartan had greater mean C (248.8 ± 28.6 vs 153.5 ± 20.9 µL, P= 0.01), no significant change in mean Pdet (24.7 ± 1.6 vs 28.8 ± 2.1 mm Hg, P= 0.2) and a higher mean NVC1 (47% vs 24%, P= 0.02).
• ? Treatment with losartan mediated an insignificant reduction in mean bladder weight (68.1 ± 9.1 mg vs 93.2 ± 11.7 mg, P= 0.10), but a significant reduction in detrusor muscle thickness (median 2 vs 3, P= 0.02). Losartan did not mediate any significant structural or functional changes in the unobstructed mouse bladder.

CONCLUSION

• ? In a mouse model of BOO, treatment with an AT‐1 antagonist partially prevented the urodynamic and structural changes that otherwise occur with BOO.

     

Reduction of moderate-to-large cystocele during urodynamic evaluation using a vaginal gauze pack: 8-year experience

OBJECTIVE: To determine the effect of cystocele reduction by a vaginal gauze pack on urodynamic studies (UDS). PATIENTS AND METHODS: UDS from consecutive women with symptomatic pelvic organ prolapse were reviewed. The protocol included a 'fill-void' study with a vaginal gauze pack, and then repeated without the pack. Tracings were categorized based on filling cystometrograms (CMGs) and pressure-flow studies (PFS). RESULTS: Of 202 women, 121 with a mean (sd) age of 67 (9.4) years contributed 221 interpretable 'pack, then no-pack' UDS (111 CMGs and 110 PFS); 77 of the women had a moderate cystocele and 44 had a large cystocele. Eighty-five women had urethral hypermobility (UH), and 36 had a well-supported urethra (WSU). The pack unmasked stress urinary incontinence (SUI) in 6% of women, with a mean (sd, range) Valsalva leak-point pressure of 54 (22, 23-90) cmH(2)O. SUI occurred more often in women with UH than WSU. Detrusor overactivity occurred similarly in pack (15%) and no-pack (14%) tracings. Bladder outlet obstruction (BOO) was relieved by the pack in 25 studies and caused by the pack in four. Women with WSU had BOO more often than those with UH (43% vs 22%, P < 0.05), regardless of the presence or absence of the pack. CONCLUSION: Unmasked SUI by pack reduction was uncommon, presumably due to anterior vaginal wall stabilization, as the pack rarely caused BOO. Those with SUI had Valsalva leak-point pressures suggestive of intrinsic sphincter deficiency. The pack did not significantly influence the presence of detrusor overactivity.     

良性前列腺增生患者膀胱出口梗阻和逼尿肌功能的分析

目的：探讨尿动力学检查对BPH患者膀胱出口梗阻（BOO）和逼尿肌功能的诊断意义.方法：对95例BPH患者进行压力-容积和压力-流率测定.结果：95例BPH患者中BOO 57例,无BOO23例,其余15例为可疑或分析困难.BOO组前列腺体积大于无BOO组（62.4±16.1）cm^3 vs（41.0±7.1）cm^3（P＜0.05）,最大尿流率（Qmax）小于无BOO组（5.4±1.9）ml/s vs（12.4±5.0）ml/s（P＜0.05）,两组IPSS评分无差别（23.7±4.4）分vs（25.2±4.9）分（P＞0.05）.BOO组有逼尿肌不稳定收缩（DD34例,无BOO组D119例.结论：尿动力学检查有助于判断有无BOO存在,了解BPH患者的逼尿肌功能.IPSS不能判断患者的下尿路症状（LUTS）是否因BOO导致.BPH患者前列腺体积不足很大,但LUTS明显时,应行尿动力学检查.自由尿流率测定对BOO诊断有一定帮助.DI是无BOO患者发生LUTS的重要因素.     

Challenging the maximum flow rate: a new index of voiding dysfunction in men with benign prostatic enlargement

OBJECTIVES

To present the theoretical development and clinical relevance of a new index of voiding dysfunction (D) based purely on free uroflow (FF), to assist in the management of patients with benign prostatic enlargement (BPE), and to compare its merits against the maximum flow rate (Q_max).

PATIENTS AND METHODS

In the Valentini‐Besson‐Nelson (VBN) micturition model for men, two variables characterize urethral obstruction, i.e. the prostatic urethral counter‐pressure pucp and the detrusor force coefficient k. D can be obtained from a FF assuming a normal detrusor (k = 1). Clinically, multiple FF from patients entered in a double‐blind pharmacological trial provided variations of D over time. D values were also compared before and after transurethral resection of the prostate (TURP).

RESULTS

In 137 patients with BPE from several institutions, D was more precise than Q_max because D is independent of volume and of perturbations of short duration during the flow. The change in D was proportionate to the invasiveness of treatment; the mean (sd ) decrease after TURP was 14.6 (8.7) cmH₂O, vs 8.1 (5.4) cmH₂O after 90 days of α‐blocker intake. Retrospectively, the range of D fitted with the clinician’s decision, i.e. pharmacological trial (16–31 cmH₂O) vs TURP (27–46 cmH₂O; P < 0.001).

CONCLUSION

The new index (D), deduced from the VBN analysis of only FF, is responsive to treatment. This simple calculation offers an insight into the voiding status of a patient with BPE beyond that obtained by Q_max alone.     

Development and validation of a new treatment outcome score for men with LUTS

AIMS: To develop, validate, and test elements of a new outcome score for men with lower urinary tract symptoms (LUTS). METHODS: Elements of well-established questions from the International Prostate Symptom Score (IPSS) assessment were combined with both established noninvasive objective determinants of voiding function including maximum uroflow (Qmax), postvoid residual urine volume (PVR), total number voids, maximum voided volume (MVV) as well as a subjective patient assessment parameter, to create a new LUTS treatment outcome instrument which we have termed the "LUTS outcome score" (LOS). The LOS is comprised of eight items; each assigned a score of 0, 1, or 2. Thus, the score ranges from 0 (best) to 16 (worst). Patients were divided into surgical/non- surgical (pharmacologic or behavior modification) treatment groups. Content validity and cutoff values for cure/improve/fail were established by an expert panel. Criterion validity was established by comparison to the IPSS. Internal reliability analysis was performed to obtain information about the relationships between individual items in the scale. Individual LOS items were correlated with the subjective outcome score. We also calculated the correlations between the LOS, IPSS, subjective post-treatment response, and age. Internal consistency, based on the average inter-item correlation was calculated using Cronbach's alpha statistic. Associations between continuous variables were examined by calculating the Pearson correlation coefficient, and between ordinal variables, using Spearman's rho. Test-retest analysis was recorded to determine reproducibility of the patient subjective outcome score. Seventy-seven men who underwent treatment for LUTS for at least 6 months participated in the study. All completed a detailed pretreatment and post-treatment clinical evaluation consisting of history/physical, questionnaire, voiding diary, urinalysis, Q, PVR, and videourodynamic study. Subjective responses of cured/improved/failed status following treatment were assessed by independent investigators. RESULTS: A high level of internal consistency was observed among the LOS symptom questions, Cronbach's alpha = 0.81 for the total cohort. The LOS correlated directly and significantly with the patient's subjective post-treatment response (r = 0.75, P < 0.001), age (r = 0.27, P = 0.02), and with the total IPSS (r = 0.62, P < 0.001). The IPSS also correlated directly and significantly with the patient's subjective post-treatment response (r = 0.48, P < 0.001) but did not correlate with the patient's age (r = 0.10, P = 0.41). When the subjective parameter for post-treatment response was subtracted from the LOS, the resulting correlation (r = 0.52, P < 0.001) approximated that obtained using the IPSS. CONCLUSIONS: The LOS is valid and internally consistent. Unlike the IPSS, it combines subjective, semisubjective, and objective parameters. Because of the objective components, it diminishes the possibility of overestimating cure and underestimating improvement relying only on patient's symptoms. Further, we believe it will prove to be useful for post hoc analysis in patients who have not had pre-treatment assessment.     

Percutaneous tibial nerve stimulation in the treatment of overactive bladder: urodynamic data.

AIM: The aim of this study was to evaluate urodynamic changes after percutaneous tibial nerve stimulation (PTNS) for the treatment of complaints related to overactive bladder syndrome and to search for urodynamic-based predictive factors. METHODS: Ninety consecutive patients with symptoms related to overactive bladder syndrome were enrolled in this study. Patients underwent 12 PTNS sessions. For evaluating objective success, the primary outcome measure was a reduction in number of urinary leakage episodes of 50% or more per 24 hours. Patients' request for continuation of therapy was considered subjective success. This study focussed on urodynamic features at baseline and on changes found after 12 PTNS treatments. RESULTS: The objective success rate was 56% (leakages/24 hours). Subjective success rate was 64%. Frequency/volume chart data and quality of life scores improved significantly (P < 0.01). Pre- and posturodynamic data were available from 46 participants. Detrusor instabilities (DI) could be abolished in a few cases only. Increments in cystometric bladder capacity and in volume at DI were significant (P = 0.043 and 0.012, respectively). Subjects without detrusor instabilities at baseline were 1.7 times more prone to respond to PTNS (odds ratio, 1.75; 95% confidence interval [CI], 0.67-4.6). The more the bladder overactivity was pronounced, the less these patients were found to respond to PTNS, the area under the receiver operating curve was 0.644 (95% CI, 0.48-0.804). CONCLUSION: PTNS could not abolish DI. PTNS increased cystometric capacity and delayed the onset of DI. Cystometry seemed useful to select good candidates: patients without DI or with late DI onset proved to be the best candidates for PTNS.     

Detrusor instability with equivocal obstruction: A predictor of unfavorable symptomatic outcomes after transurethral prostatectomy

AIMS: To elucidate whether preoperative urodynamic findings can predict outcomes of transurethral resection of the prostate (TUR-P). METHODS: Sixty-two patients with symptomatic benign prostatic hyperplasia were categorized in three different ways based on findings of preoperative pressure-flow study (PFS) and cystometry: urodynamic obstruction (determined by the Abrams-Griffiths nomogram), detrusor instability (DI), and combination of both. Outcomes of TUR-P regarding symptom, function, and quality of life (QOL) were analyzed by changes in the International Prostate Symptom Score (I-PSS), maximum flow rate in uroflowmetry, and QOL index before and after TUR-P, respectively. Overall outcome was defined as success when all of the three categories showed successful improvement. RESULTS: Neither urodynamic obstruction alone nor DI alone predicted outcomes of TUR-P. However, symptomatic and overall outcomes were significantly worse in patients who were not obstructed but had DI. Postoperative persistent DI was more frequently noted in patients without clear obstruction (60%) than in those with obstruction (27%). Patients with equivocal obstruction showed less satisfactory symptomatic outcomes of TUR-P when DI was accompanied. Persistent DI might be the principle cause of unfavorable outcomes. CONCLUSIONS: Preoperative evaluation of DI is of benefit because it enhances predictive value of the PFS.     

女性膀胱颈纤维化导致膀胱出口梗阻的诊治（附22例报告）

目的报告女性膀胱颈纤维化导致膀胱出口梗阻（BOO）的诊断治疗体会。方法膀胱颈纤维化导致BOO女性病例22例，经尿流动力学及膀胱镜检确诊，均行经尿道膀胱颈部分切除术，并联合药物治疗。结果随访2～15个月，排尿情况均有改善，最大尿流率〉15mL／s，国际前列腺症状评分（IPSS）5．2±1．6。病理报告显示所有病例膀胱颈组织纤维增生，其中合并慢性炎症改变10例。结论根据临床症状、尿流动力学检查及膀胱镜检可以明确诊断膀胱颈纤维化导致的BOO，经尿道膀胱颈部分切除术可以取得良好的治疗效果。