功能性膀胱出口梗阻的诊断与治疗

目的　探讨功能性膀胱出口梗阻的诊断和治疗方法。　方法　 1995年 10月至 2 0 0 2年10月 ,因排尿困难就诊的男性患者 39例 ,经尿动力学检查、排尿期膀胱尿道造影及尿道扩张器探查尿道等确诊为功能性膀胱出口梗阻。国际前列腺症状评分 (IPSS)平均 2 2 .5分 ,最大尿流率平均 10 .2ml/s,剩余尿量平均 12 4ml。所有患者应用经尿道内括约肌切开术及α 受体阻滞剂治疗。　结果　平均手术时间 15min ;平均出血 5 0ml;术后平均住院 3.5d。所有患者疗效满意 ,排尿症状明显改善。术后 1年随访平均IPSS 10 .1分 ,平均最大尿流率 2 2 .1ml/s,剩余尿量平均 4 9ml,与治疗前比较差异均有显著性意义 (P <0 .0 5 )。　结论　联合应用尿动力学检查、排尿期膀胱尿道造影及尿道扩张器探查尿道等方法可准确诊断功能性膀胱出口梗阻。经尿道内括约肌切开术及α 受体阻滞剂是有效的治疗方法。     

Etiology of voiding dysfunction in men less than 50 years of age

Objectives

Chronic lower urinary tract symptoms in young men are often attributed to misdiagnosed chronic nonbacterial prostatitis. The purpose of this study was to analyze etiology of chronic voiding dysfunction in men less than 50 years of age.

Methods

The videourodynamic studies of 137 men 50 years of age or less with chronic voiding dysfunction, performed between January 1990 and October 1995, were retrospectively analyzed.

Results

The distribution of urodynamic abnormalities included 74 (54%) patients with primary vesical neck obstruction, 33 (24%) with obstruction localized to the membranous urethra (pseudodyssynergia), 23 (17%) with impaired bladder contractility, and the remaining 7 (5%) with an acontractile bladder. Detrusor instability was present in 67 men (49%).

Conclusions

Voiding dysfunction among young men is common and is often misdiagnosed. Videourodynamic evaluation is very useful in establishing the correct diagnosis and ultimately in delivery of appropriate therapy.     

An observational urodynamic evaluation of men with lower urinary tract symptoms treated with doxazosin

Objectives

To assess the urodynamic changes in men with lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction treated with doxazosin and to correlate these changes with voiding symptoms.

Methods

Fifty patients with LUTS were treated with doxazosin at a dose of 4 mg/day for 3 months. All men were initially evaluated by International Prostate Symptom Score (I-PSS) questionnaires, measurement of urinary flow rate and complex urodynamic study. Those patients completing the 3-month study underwent repeat testing.

Results

Forty-four (88%) men underwent initial and follow-up urodynamic evaluation. The mean I-PSS improved from 20.6 to 10.6 (P <0.001), mean peak urinary flow rate increased from 11.7 to 13.2 cc/s (P = 0.20), mean detrusor pressure at peak flow decreased from 93.6 to 83.0 cm H(in2)O (P = 0.15) and mean cystometric bladder capacity increased from 266 to 304 cc (P = 0.07). Using the Abrams-Griffiths nomogram and number, more than 58% of patients remained obstructed after treatment with doxazosin for 3 months. Men with and without objective evidence of bladder outlet obstruction at the outset of the study had similar improvement in voiding symptoms. Most patients elected to continue treatment with doxazosin at the completion of the study (41/44, 93%).

Conclusions

The majority of patients had objective evidence of persistent bladder outlet obstruction after treatment with doxazosin for 3 months despite significant subjective benefit. The results of complex urodynamic evaluation did not predict treatment response in men with LUTS suggestive of bladder outlet obstruction. Urodynamic study does not appear to be helpful in the evaluation of patients with uncomplicated LUTS prior to treatment with doxazosin.     

The Correlation Between Bladder Outlet Obstruction and Lower Urinary Tract Symptoms as Measured by the International Prostate Symptom Score

Purpose

We studied the relationship between lower urinary tract symptoms as measured by the international prostate symptom score (I-PSS) and urodynamic findings in elderly men.

Materials and Methods

We evaluated 803 consecutive patients with lower urinary tract symptoms via the I-PSS and urodynamics with pressure-flow studies.

Results

A statistically significant correlation was found between all I-PSS questions (except intermittency) and objective parameters of obstruction. However, the clinical significance of this finding is minimal because a large overlap of symptom scores exists among patients with different grades of bladder outlet obstruction. The filling component of the I-PSS correlated somewhat better with obstruction than did the voiding component.

Conclusions

It seems impossible to diagnose bladder outlet obstruction from symptoms alone. It does not even seem possible to define subgroups in which further urodynamic examination is indicated.     

Management of functional bladder neck obstruction in women: use of alpha-blockers and pediatric resectoscope for bladder neck incision

PURPOSE: Functional bladder neck obstruction has been definitively diagnosed in the last few years due to detailed synchronous pressure flow, electromyography and video urodynamics. Clean intermittent self-catheterization and bladder neck incision are the modalities of treatment. To our knowledge the role of alpha-blockers is not yet defined in women. A new technique was developed to perform bladder neck incision using a pediatric resectoscope. MATERIALS AND METHODS: A total of 24 women with obstructive voiding symptoms or retention were evaluated with video pressure flow electromyography, and diagnosed with functional bladder neck obstruction due to high pressure and low flow on silent electromyography and bladder neck appearance on fluoroscopy. Patients were initially treated with clean intermittent self-catheterization and alpha-blockers. Catheterization was stopped when post-void residual was less than 50 ml. and only alpha-blocker therapy was continued. Bladder neck incision was performed in patients who had a poor response to or side effects of alpha-blocker therapy, or when therapy was discontinued due to economic reasons. Clean intermittent self-catheterization was continued in patients who had a poor response to alpha-blockers or refused to undergo bladder neck incision. Bladder neck incision was performed in the initial 2 cases with an adult resectoscope using a Collin's knife and subsequently a pediatric resectoscope (13F). Uroflow and post-void residual measurements were performed in all cases. RESULTS: Of the 24 patients 12 (50%) showed improvement in symptoms, peak flow and post-void residual (p <0.01) with alpha-blocker therapy only. Of the 12 patients who had a poor response to alpha-blockers 6 underwent bladder neck incision subsequently and 6 remained on clean intermittent self-catheterization. All 8 patients treated with bladder neck incision, including 2 who had a good response but discontinued alpha-blocker therapy, had sustained improvement in post-void residual and peak flow (p <0.01) after a mean followup of 3.8 +/- 2.4 years. Grade 1 stress incontinence in 2 adult resectoscope cases responded to conservative treatment. None of the pediatric resectoscope cases had stress incontinence. CONCLUSIONS: Clean intermittent self-catheterization and alpha-blockers are the initial treatment options for functional bladder neck obstruction. The alpha-blockers were successful in 50% of our patients. Bladder neck incision should be offered judiciously with minimal risk of curable stress incontinence. The pediatric resectoscope is useful to make a well controlled incision safely in the female urethra.     

Detrusor Contractility and Compliance Characteristics in Adult Male Patients With Obstructive and Nonobstructive Voiding Dysfunction

Purpose

To understand better the contractility and compliance characteristics of the detrusor in patients with varying degrees of outlet obstruction, we analyzed urodynamic studies in elderly men with obstructive and nonobstructive voiding dysfunction.

Materials and Methods

All patients were evaluated with video urodynamics, including cystometry, isometric tests, voiding profilometry and post-void residual measurement. Bladder compliance, detrusor contractility, detrusor reserve, detrusor instability and the severity of outlet obstruction were determined in each patient. Patients were stratified into 4 groups: urodynamically normal, detrusor instability, outlet obstruction and outlet obstruction with detrusor instability.

Results

A significant correlation was found between the maximum isometric contraction pressure and the severity of obstruction in 168 patients. Maximum isometric contraction pressure was significantly greater in patients with than without obstruction, independent of detrusor instability. Although compliance was not significantly different among the groups, the proportion of patients with poor compliance (less than 30 ml./cm. water) was lowest in the normal group. The detrusor reserve was significantly less in patients with chronic retention (post-void residual more than 200 ml.) than in those with lower post-void residuals.

Conclusions

The increase in detrusor contractility with increasing outlet obstruction suggests a compensatory response to obstruction. Furthermore, a decrease in bladder compliance does not appear to be a consistent finding in patients with outlet obstruction,although the proportion of patients with poor compliance is higher in the group with obstruction and/or detrusor instability than in those with normal urodynamic findings. The decrease in detrusor reserve in patients with high post-void residual volumes suggests that the detrusor reserve reflects the degree of detrusor decompensation.     

Treatment of obstructive uropathy in one of three young brothers suffering from Gorlin-Cohen syndrome: a case report

Background

Frontometaphyseal dysplasia, or Gorlin-Cohen syndrome, is an X-linked disorder primarily characterized by skeletal dysplasia, such as hyperostosis of the skull and abnormalities of tubular bone modeling. Some patients develop extraskeletal manifestations, such as urinary tract anomalies.

Case presentation

A 26-year-old male patient was diagnosed with frontometaphyseal dysplasia and suffered from chronic urine retention. Although the patient was primarily diagnosed with a neurogenic bladder, our work-up revealed posterior urethral valves, bladder neck stenosis, and multiple bladder stones. The patient was treated by transurethral resection of the urethral valves and bladder neck with simultaneous open cystolithotomy to remove the bladder calculi. After removal of the catheter, the patient voided normally and had no post-void residual urine. At the 1-year follow-up, he was still voiding normally; his urodynamic investigation was also normal.

Conclusions

In the recent literature, there is scarce information on the diagnosis, treatment, and follow-up of patients with malformations of the urinary tract as a result of Gorlin-Cohen syndrome. The case presented here could guide urological approaches to patients suffering from this rare condition.     

Pseudodyssynergia (Contraction of the External Sphincter During Voiding) Misdiagnosed as Chronic Nonbacterial Prostatitis and the Role of Biofeedback as a Therapeutic Option

Purpose

Chronic lower urinary tract symptoms in young men are often attributed to misdiagnosed chronic nonbacterial prostatitis. We analyzed contraction of the external urinary sphincter during voiding (pseudodyssynergia) as an etiology of voiding dysfunction in men with misdiagnosed chronic prostatitis.

Materials and Methods

The video urodynamic studies of 43 men 23 to 50 years old with chronic voiding dysfunction secondary to pseudodyssynergia performed between January 1990 and June 1996 were retrospectively analyzed. Pseudodyssynergia was diagnosed based on several criteria, including electrical activity of the external sphincter during voiding in the absence of abdominal straining, and brief and intermittent closing of the membranous urethra during voiding detected by electromyography and fluoroscopy. Patients with bacterial infection or excessive leukocytes in expressed prostatic secretions were excluded from the study.

Results

Of the patients 39 (91%) were firstborn men. Duration of symptoms ranged from 17 to 146 months (mean 43.6). Average number of previous antibiotic days ranged from 53 to 186 (mean 67.6). In addition, empirical trials of alpha-blockers were unsuccessful. Mean American Urological Association symptom score plus or minus standard deviation was 17.5 +/- 3.7, mean maximum flow rate was 13.3 +/- 4.2 ml. per second, mean detrusor pressure at maximum flow was 46.3 +/- 13.7 cm. water and mean detrusor contraction duration was 132.8 +/- 27.7 seconds. Behavior modification and biofeedback were successful in decreasing symptoms in 35 patients (83%) at 6 months.

Conclusions

These results indicate that some men who are categorized as having and empirically treated for chronic nonbacterial prostatitis are misdiagnosed and, in fact, have functional bladder outlet obstruction. Urodynamics are helpful in diagnosing and predicting success with behavior modification and biofeedback in these patients.     

Transurethral incision of the bladder neck: An objective and subjective evaluation of its efficacy

This study is designed to evaluate the efficacy of treatment of bladder neck obstruction using objective (urodynamic) and subjective (assessment of satisfaction) parameters and to investigate sexual function. The results of transurethral 4 and 8 o'clock incisions of the bladder neck in 62 men (mean age 48.5 years) were reviewed with a mean follow-up of 6–12 months. Preoperative urodynamic evaluation was compared to recent postoperative urodynamic evaluation. There is marked symptomatic improvement after transurethral incision of the bladder outlet. The mean peak urine flow rate increased from 7.2 ml/s to 16.8 ml/s. Fifty-three men (85.4%) reported long-term improvement after transurethral incision of the bladder neck with an overall satisfaction rate of 71% (range 0 to 100). Five men (8%) reported new retrograde ejaculation after transurethral incision of the bladder neck. These results demonstrate that in well selected, properly diagnosed cases 4 and 8 o'clock transurethral incision of the bladder neck is an effective procedure for long-term relief of bladder outlet obstruction.     

Differential Diagnosis of Prostatism: a 12-year Retrospective Analysis of Symptoms, Urodynamics and Satisfaction with Therapy

Purpose

We determined the incidence of voiding symptoms, urodynamic etiology and satisfaction with therapy in a large cohort of men with prostatism during a 12-year period.

Materials and Methods

We retrospectively analyzed the records of 2,845 consecutive men who underwent urodynamic evaluation between January 1982 and December 1994. Patients were divided into groups 1 and 2 according to the years of study (between 1982 and 1988, and between 1989 and 1994, respectively). Parameters of evaluation included prevalence and distribution of voiding symptoms, urodynamic etiology of symptoms and satisfaction with therapy (medical or surgical).

Results

There was 843 evaluable patients 50 to 94 years old (mean age 63.2). Group 2 patients were younger, and had a 22 percent higher prevalence of nocturia and a 12 percent higher prevalence of daytime frequency. The prevalence of all other symptoms was the same in both groups. On urodynamics 523 patients (62 percent) had demonstrable evidence of bladder outlet obstruction of whom 345 (66 percent) had concomitant detrusor instability. Of the 843 patients 647 (77 percent) had detrusor instability, which was the sole diagnosis in 199 (24 percent). We noted low pressure/low flow in 137 patients (16 percent) and impaired detrusor contractility in 152 (17 percent), including 57 (7 percent) in whom the latter condition was the only diagnosis. Urodynamic findings remained the same during the entire 12-year period. Global satisfaction and symptomatic improvement were better with surgical than medical therapy, although the degree of satisfaction was independent of the urodynamic etiology of symptoms.

Conclusions

Symptomatic men with prostatism are presenting with a greater prevalence of significant nocturia and daytime frequency than in the past with no change in urodynamic findings. In addition, patient level of satisfaction remains greater with surgical than medical therapy regardless of the urodynamic presence of bladder outlet obstruction.     

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.     

Age and bladder outlet obstruction are independently associated with detrusor overactivity in patients with benign prostatic hyperplasia

Background

Detrusor overactivity is one known cause of lower urinary tract symptoms and has been linked to bladder storage symptoms (urgency, frequency, or urge incontinence).

Objective

To determine clinical and urodynamic parameters associated with detrusor overactivity in patients with suspected benign prostatic hyperplasia.

Design, Setting, and Participants

During 1993–2003, urodynamic investigations were performed in patients aged 40 yr or older and with lower urinary tract symptoms, benign prostatic enlargement, and/or suspicion of bladder outlet obstruction (maximum flow rate < 15 ml/s or postvoid residual urine > 50 ml).

Measurements

Detrusor overactivity was defined according to the new International Continence Society classification (2002) as involuntary detrusor contractions during cystometry, which may be spontaneous or provoked, regardless of amplitude. The Schäfer algorithm was used to determine bladder outlet obstruction.

Results

In total, 1418 men were investigated (median age: 63 yr) of whom 864 men (60.9%) had detrusor overactivity. In univariate analysis, men with detrusor overactivity were significantly older, more obstructed, had larger prostates, higher irritative International Prostate Symptoms Score subscores, a lower voiding volume at free uroflowmetry, and a lower bladder capacity at cystometry. The prevalence of detrusor overactivity rose continuously with increasing bladder outlet obstruction grade. Multivariate analysis showed that only age and bladder outlet obstruction grade were independently associated with detrusor overactivity. After age adjustment, the odds ratios of detrusor overactivity compared to Schäfer class 0 were 1.2 for class I, 1.4 for class II, 1.9 for class III, 2.5 for class IV, 3.4 for class V, and 4.7 for class VI.

Conclusions

In patients with clinical benign prostatic hyperplasia, detrusor overactivity is independently associated with age and bladder outlet obstruction. The probability of detrusor overactivity rises with increasing age and bladder outlet obstruction grade.     

The Role of Urodynamics in the Evaluation of Voiding Dysfunction in Men after Cerebrovascular Accident

Purpose

The etiology of voiding dysfunction was determined in men after a cerebrovascular accident who were at risk for obstructive uropathy to evaluate whether the cause of voiding dysfunction could be predicted by the type (obstructive or irritative) or onset of symptoms.

Materials and Methods

We evaluated 38 men with complaints of voiding dysfunction following a cerebrovascular accident. All patients were of the age when bladder outlet obstruction secondary to benign prostatic hyperplasia would otherwise be prevalent. After a comprehensive history and physical examination, all patients underwent multichannel urodynamic studies at a medium fill rate (20 to 50 ml. per minute). Findings were classified by the Abrams-Griffiths nomogram as obstruction, no obstruction or equivocal.

Results

Mean patient age was 70 years (range 54 to 87). Patients were grouped according to the presenting voiding complaints (purely irritative in 42 percent, purely obstructive in 34 percent or mixed in 24 percent). In 34 patients (89 percent) the onset of symptoms paralleled the occurrence of the cerebrovascular accident. Detrusor hyperreflexia was noted in 82 percent of the patients. There was no statistically significant difference in the occurrence of detrusor hyperreflexia among the 3 symptom groups (Fisher's exact test). Pressure-flow analysis clearly showed obstruction in 24 patients (63 percent), no obstruction in 9 (24 percent) and equivocal results in 5 (13 percent) according to the nomogram. There was no statistically significant difference in the incidence of obstruction among the 3 symptom groups (Fisher's exact test).

Conclusions

Presenting symptoms did not predict the urodynamic findings of bladder outlet obstruction or detrusor hyperreflexia. The significant incidence of onset of symptoms after stroke suggests that the cerebrovascular accident induced voiding dysfunction in the face of preexisting bladder outlet obstruction may exacerbate the symptoms of the latter condition or vice versa.     

Clinical Diagnosis of Bladder Outlet Obstruction in Patients with Benign Prostatic Enlargement and Lower Urinary Tract Symptoms: Development and Urodynamic Validation of a Clinical Prostate Score for the Objective Diagnosis of Bladder Outlet Obstruction

Purpose

We attempted to improve the method of objective clinical evaluation of patients with benign prostatic enlargement and lower urinary tract symptoms.

Materials and Methods

We compared the results of free uroflowmetry and transrectal ultrasound prostate size determination with those of pressure-flow analysis of bladder outlet obstruction in 871 consecutive elderly men.

Results

Maximal flow, prostate size, and post-void residual and voided volumes were correlated with bladder outlet obstruction to derive a clinical prostate score.

Conclusions

Clinical prostate score shows a superior correlation with bladder outlet obstruction than isolated objective parameters or symptom scores.     

Urodynamic Risk Factors for Renal Dysfunction in Men With Obstructive and Nonobstructive Voiding Dysfunction

Purpose

Urodynamic investigation of men with lower urinary tract symptoms, usually attributed to benign prostatic hyperplasia, often reveals bladder outlet obstruction, detrusor instability and/or diminished vesical compliance. We investigated whether these urodynamic abnormalities alone or in combination contribute to renal dysfunction.

Materials and Methods

A total of 161 men with lower urinary tract symptoms was evaluated by urodynamics, but outlet obstruction, detrusor instability and decreased compliance (30 ml./cm. water or less) were noted. Serum blood urea nitrogen (BUN) and creatinine were measured. Cases were categorized according to the urodynamic diagnosis. Mean values of serum BUN and creatinine as well as the incidence of elevated BUN and creatinine were compared among groups.

Results

of the cohort 54 men (34%) had elevated BUN and 19 (12%) had elevated serum creatinine. No significant correlation was found between the degree of obstruction and BUN or creatinine level. Mean serum BUN and creatinine, and the incidence of abnormal laboratory tests did not significantly differ among those with outlet obstruction, detrusor instability, both conditions or neither condition. However, in patients with outlet obstruction and detrusor instability there was a significantly increased incidence of azotemia in the subgroup with diminished compliance (78%) versus the subgroup with normal compliance (36%).

Conclusions

In men with voiding dysfunction of a nonneurogenic etiology outlet obstruction with or without detrusor instability does not appear to be a risk factor for elevated BUN and creatinine. However, when decreased bladder compliance is associated with a combination of outlet obstruction and detrusor instability, this risk is substantially increased.     

女性功能性膀胱出口梗阻的诊断与治疗

目的探讨女性功能性膀胱出口梗阻的诊断与治疗方法。方法28例因排尿困难就诊的女性患者,经尿流动力学检查,排尿期膀胱造影及膀胱镜检查等确诊为功能性膀胱出口梗阻。平均最大尿流率11.3ml/s,平均剩余尿量180ml。所有患者接受经尿道内括约肌切开术和α鄄受体阻滞剂治疗。结果平均手术时间15min;术后平均住院4d,所有患者排尿顺畅,症状明显改善。术后10月随访,平均最大尿流率25.7ml/s,平均剩余尿量30ml,与治疗前相比差异显著(P<0.05)。结论联合应用尿流动力学检查,排尿期膀胱尿道造影及膀胱镜检查可准确诊断功能性膀胱出口梗阻。经尿道内括约肌切开术及α鄄受体阻滞剂治疗是较理想的治疗方法之一。     

Endoscopic treatment of bladder outlet obstruction in men after pancreas transplantation.

PURPOSE: Diabetic cystopathy comprises a spectrum of voiding dysfunction. The usual clinical manifestations are impaired bladder sensation and detrusor contractility. Diabetic cystopathy is present in as many as 43 to 85% of patients undergoing pancreas transplantation. We evaluated endoscopic management of bladder outlet obstruction for adjuvant treatment of urological complications after pancreas transplantation. MATERIALS AND METHODS: We evaluated 10 men with recurrent urological complications, including bladder leak, urinary tract infection, the dysuria/urethritis syndrome and reflux nephropathy, after pancreas transplantation. Evaluation consisted of peak flow rate, post-void residual and written questionnaires in all cases, and preoperative urodynamics in 2. All patients had signs and symptoms of bladder outlet obstruction at post-transplant presentation and underwent bladder neck incision, direct visual internal urethrotomy, limited transurethral resection of the bladder neck or transurethral resection of the prostate. Hospital costs, including operating room, laboratory, pharmacy, hospital room occupancy, anesthesia and radiology fees, were obtained from the University of Washington. RESULTS: Mean peak flow rate plus or minus standard deviation increased from 10.1+/-3.2 to 21.0+/-5.1 cc per second and post-void residual decreased from 259.2+/-38.6 to 43.6+/-36.8 cc after endoscopic intervention. Of the patients 4 presented early (mean 4.3 months) after transplantation with bladder leak or reflux nephropathy, while late presentation (mean 43 months) was associated with recurrent urinary tract infection, the urethritis/dysuria syndrome and more obstructive symptoms. Complications resolved in all cases after surgery and enteric conversion, which costs 5-fold more than endoscopic intervention, was avoided. CONCLUSIONS: Recurrent urological complications warrant early evaluation for occult bladder dysfunction. Endoscopic procedures to relieve outlet obstruction are beneficial in alleviating recurrent urological complications in men after pancreas transplantation. This cost-effective and low morbidity procedure may obviate the need for enteric conversion in some male transplant recipients.     

Indikationen zur urodynamischen Untersuchung

Background

The aim of urodynamic testing is to obtain objective information regarding urinary bladder storage and voiding function. Basic investigations provide information of the underlying incontinence form. Depending on the individual situation and findings, further urodynamic investigations are helpful or indicated. Prior to conservative therapy, a routine urodynamic investigation is not indicated.

Objectives

Due to limited evidence of preoperative urodynamic investigations on postoperative results, the urodynamic results may be helpful when considering various treatment options.

Results

Urodynamic investigations should be performed preoperatively, especially in case of overactive bladder symptoms, prior incontinence surgery, or disordered bladder emptying. The assessment of urethral function should be considered in the urodynamic investigation of stress urinary incontinence. In patients with pelvic prolapse, urodynamic investigations should be performed during prolapse reposition.

     

A COMPARATIVE STUDY OF THE ABRAMS-GRIFFITHS NOMOGRAM AND THE LINEAR PASSIVE URETHRAL RESISTANCE RELATION TO DETERMINE BLADDER OUTLET OBSTRUCTION

Purpose

The Abrams-Griffiths and linear passive urethral relationship (PURR) nomograms are commonly used to diagnose bladder outlet obstruction. To the best of our knowledge there are no clinical studies comparing these 2 evaluations to determine if they similarly predict the findings of bladder outlet obstruction.

Materials and Methods

From October 1994 through December 1996 multichannel urodynamic studies were performed in 72 men with lower urinary tract symptoms. The data from each urodynamic study were plotted on the Abrams-Griffiths and PURR nomograms.

Results

Using the Abrams-Griffiths nomogram 23 patients (46%) were unobstructed, 15 (21%) were equivocal for obstruction and 24 patients (33%) were obstructed. When the linear PURR nomogram was applied to the pressure-flow data in each group all unobstructed cases were categorized into grade 0 or 1 (no obstruction), equivocal into grade 2 (mild obstruction) and obstructed into grades 3 through 6 (moderate to severe obstruction).

Conclusions

The Abrams-Griffiths and linear PURR nomograms are helpful and comparable clinical tools to assess lower urinary tract symptoms in men. The linear PURR nomogram not only detects the presence of bladder outlet obstruction but grades its severity, which may be helpful to monitor treatment.     

Post-void residual urine under 150 ml does not exclude voiding dysfunction in women

Introduction and hypothesis

It has been claimed that post-void residual urine (PVR) below 150 ml rules out voiding dysfunction in women with stress urinary incontinence (SUI) and provides license to perform sling surgery. The cut-off of 150 ml seems arbitrary, not evidence-based, and so we sought to investigate the ability of PVR?<?150 ml to exclude voiding dysfunction.

Methods

We retrospectively reviewed the charts of all patients who underwent invasive urodynamics from 1 January 2013 to 31 December 2013. Voiding dysfunction was diagnosed if both the invasive urodynamic and the free flow showed abnormal results. We registered the PVR in patients with voiding dysfunction and divided them into groups with PVR?<?150 ml and PVR?≥?150 ml. Patients were then analyzed for bladder outlet obstruction and detrusor underactivity.

Results

Of the 205 patients undergoing invasive urodynamics in 2013, a total of 20 had voiding dysfunction, 2 with PVR?≥?150 ml. Eighteen patients had PVR?<?150 ml (range 0–50 ml); 9 had bladder outlet obstruction while 7 had detrusor underactivity. Two patients were uncategorized. Out of the 20 patients, 7 had no symptoms or complaints indicating voiding dysfunction.

Conclusions

Patients with voiding dysfunction often have normal PVR and so PVR?<?150 ml cannot exclude voiding dysfunction. All patients should be evaluated using free flow measurements along with PVR to obtain a reliable, objective measurement of their voiding pattern, before anti-incontinence surgery.