Detrusor Underactivity Patients Research Articles

Urine biomarker could be a useful tool for differential diagnosis of a lower urinary tract dysfunction.

A precision diagnosis of lower urinary tract dysfunctions (LUTD) such as bladder outlet obstruction, detrusor overactivity (DO), interstitial cystitis/bladder pain syndrome (IC/BPS), dysfunctional voiding (DV), or detrusor underactivity (DU) needs invasive videourodynamic study. Exploring non-invasive tools to help screening LUTD is necessary for clinicians in their daily practice. This article reviews recently clinical studies of using urinary inflammatory proteins and oxidative stress biomarkers in the identification of specific LUTD among men and women with lower urinary tract symptoms (LUTS). Some important findings have been reported: (1) Using urine chemokines CXCL-1 and interleukin-8 (IL-8), we may discriminate overactive bladder (OAB) symptoms in women between DO and urinary tract infection. (2) Urinary levels of oxidative stress biomarkers such as 8-hydroxydeoxyguanosine (8-OHdG) and 8-isoprostane have a potential being used as a tool to identify women with mixed DO and stress urinary incontinence. (3) Urine levels of total antioxidant capacity (TAC), and prostaglandin E2 (PGE2) are positively correlated with voiding detrusor pressure in patients with DU. (4) Urine levels of brain-derived neurotrophic factor (BDNF) and PGE2 were significantly higher in the DU patients with detrusor function recovery. (5) Women with DV had higher urinary levels of tumor necrosis factor-alpha (TNF-α) and 8-OHdG, and urinary IL-2 level was significantly lower. (6) Urine level of 8-isoprostane was higher in the patients with idiopathic DO and neurogenic DO. (7) Higher urine cytokine levels of monocyte chemoattractant protein-1 (MCP-1), regulated on activation, normal T-cell expressed and secreted (RANTES), CXCL-10, IL-7, and eotaxin-1 in patients with IC/BPS than controls. (8) The urine levels of IL-8, CXCL-10, BDNF, IL-6, and RANTES were significantly higher in patients with Hunner's IC than non-Hunner's IC. (9) Male patients with IC/BPS had a significantly higher level of eotaxin, MCP-1, TNF-α, 8-OHdG, and TAC. Combining a higher eotaxin and a higher TNF-α can provide a satisfactory diagnostic value in discriminating IC/BPS from other LUTD in men. These studies provide evidence that measurement of cluster of urine biomarkers could be used as a diagnostic tool to differentiate different LUTD in patients with similar LUTS.

Investigating Urine Biomarkers in Detrusor Underactivity and Detrusor Overactivity with Detrusor Underactivity Patients

Bladder inflammation and tissue hypoxia were considered important pathognomonic bladder features in detrusor underactivity (DU) and detrusor overactivity (DO) patients. This study investigated urine inflammatory and oxidative stress biomarker levels in DU and DO with DU (DO-DU) patients. Urine samples were collected from 50 DU and 18 DO-DU patients, as well as 20 controls. The targeted analytes included three oxidative stress biomarkers (8-OHdG, 8-isoprostane, and total antioxidant capacity [TAC]) and 33 cytokines. DU and DO-DU patients had different urine biomarker profiles from controls, including 8-OHdG, PGE2, EGF, TNFα, IL-1β, IL-5, IL-6, IL-8, IL-10, IL-17A, and CXCL10. Controlling for age and sex, multivariate logistic-regression models revealed that 8-OHdG, PGE2, EGF, IL-5, IL-8, IL-10, and TAC were significant biomarkers for diagnosing DU. In DU patients, urine TAC and PGE2 levels were positively correlated with detrusor voiding pressure. In DO-DU patients, urine 8-OHdG, PGE2, IL-6, IL-10, and MIP-1α levels were positively correlated with maximal urinary flow rate, while urine IL-5, IL-10, and MIP-1α were negatively correlated with the first sensation of bladder filling. Urine inflammatory and oxidative stress biomarker analysis provides a non-invasive and convenient approach for important clinical information in DU and DO-DU patients.

LBA01-20 DETRUSOR ULTRASTRUCTURAL STUDY PREDICTS LONG TERM VOIDING OUTCOMES IN MALE PATIENTS WITH DETRUSOR UNDERACTIVITY WHO UNDERWENT TRANSURETHRAL RESECTION OF PROSTATE (TURP)

You have accessJournal of UrologyCME1 Apr 2023LBA01-20 DETRUSOR ULTRASTRUCTURAL STUDY PREDICTS LONG TERM VOIDING OUTCOMES IN MALE PATIENTS WITH DETRUSOR UNDERACTIVITY WHO UNDERWENT TRANSURETHRAL RESECTION OF PROSTATE (TURP) Amanda Chung, Vincent Tse, and Lewis Chan Amanda ChungAmanda Chung More articles by this author , Vincent TseVincent Tse More articles by this author , and Lewis ChanLewis Chan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003360.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with detrusor underactivity (DU) have a variable voiding outcome after TURP which may not be predicted by urodynamics. Our previous detrusor ultrastructural studies demonstrated that features of ‘myohypertrophy pattern’ were associated with bladder outlet obstruction(BOO) and poor short term voiding outcomes. We report the largest ultrastructural study on DU and correlate detrusor ultrastructure features with long term voiding outcomes in men with urodynamic proven DU who have had TURP. METHODS: Patients with urodynamic diagnosis of DU or BOO who underwent TURP were studied. Detrusor biopsies were obtained at cystoscopy and processed for electron microscopy. Detrusor ultrastructural features including myohypertrophy pattern (cell size, irregularity), degeneration and elastosis were assessed using a simplified protocol with observers blinded to clinical data. Postoperative voiding outcomes (mean 16yrs) were correlated with ultrastructural features and urodynamic parameters. RESULTS: 27 patients (mean age 78 yrs) were recruited (23 DU and 4 BOO). In DU patients, the mean postvoid residual urine (PVR) was 630ml (IQR 240-985). Postoperatively all BOO patients voided, 9 DU patients (39%) were catheter-free at 3 months, 14 patients (61%) required catheterisation. At long term follow-up, only 29% DU (6/21) patients were catheter-free. Functional parameters including PVR, Voiding efficiency and Bladder contractility index did not correlate with voiding outcomes. Ultrastructural studies of DU patients showed voiding outcome after TURP was significantly associated with myocyte irregularity/derangement (p=0.034) and collagenosis (p=0.041). Overall, moderate to severe changes of ‘myohypertrophy’ pattern (myocyte size variation, increased cell separation, increased intercellular collagen, degeneration) predicted poor long term voiding outcomes (p=0.029, OR of catheter-dependence 5.5). CONCLUSIONS: Detrusor ultrastructural features of myocyte irregularity, degeneration, collagenosis (moderate to severe ‘myohypertrophy pattern’) are associated with impaired detrusor contractility and predicted poor long term voiding outcomes and catheter dependence after TURP. Detrusor biopsy with ultrastructural analysis can be a useful diagnostic and prognostic tool in men with DU considering surgery. Source of Funding: Royal Australasian College of Surgeons Foundation Scholarship © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1185 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amanda Chung More articles by this author Vincent Tse More articles by this author Lewis Chan More articles by this author Expand All Advertisement PDF downloadLoading ...

MP03-20 USE CLUSTER ANALYSIS TO DEVELOP AN ACCURATE AND PRACTICAL DIAGNOSTIC METHOD FOR DETRUSOR UNDERACTIVITY IN FEMALE PATIENT WITHOUT BLADDER OUTLET OBSTRUCTION

You have accessJournal of UrologyCME1 Apr 2023MP03-20 USE CLUSTER ANALYSIS TO DEVELOP AN ACCURATE AND PRACTICAL DIAGNOSTIC METHOD FOR DETRUSOR UNDERACTIVITY IN FEMALE PATIENT WITHOUT BLADDER OUTLET OBSTRUCTION Jen-Chieh Chen, Chi-Chieh Lin, Yu-Hua Fan, Shing-Hwa Lu, Alex T. L. Lin, and William J. Huang Jen-Chieh ChenJen-Chieh Chen More articles by this author , Chi-Chieh LinChi-Chieh Lin More articles by this author , Yu-Hua FanYu-Hua Fan More articles by this author , Shing-Hwa LuShing-Hwa Lu More articles by this author , Alex T. L. LinAlex T. L. Lin More articles by this author , and William J. HuangWilliam J. Huang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003214.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The International Continence Society (ICS) definition of the detrusor underactivity (DU) lacks of standardized urodynamic (UDS) parameters and thresholds. Standardized and accepted nomograms for the DU diagnosis have been reported only for men, while there are no definitive standardized UDS criteria for the definition of female DU. We propose to use the cluster analysis to identify DU among female patient without bladder outlet obstruction (BOO) on the daily practice. METHODS: We retrospectively reviewed our video-urodynamic study (VUDS) database from 2015 to 2020. All female patients with “weak stream” subscore of International Prostate Symptom Score equal or greater than 3 points were included. The exclusion criteria were patients who had radiological evidence of BOO and situational inability to void on VUDS. The VUDS results were reviewed by two independent researchers, and DU was diagnosed based on the ICS criteria. A total of 80 patients were enrolled, and we divided them into discovery (from 2018 to 2020) and validation cohort (from 2015 to 2018). Hierarchical cluster analysis and K-means clustering were performed with UDS parameters which included detrusor pressure at maximum flow (PdetQmax), maximal urine flow rate (UFR), and voiding time. RESULTS: Three groups could be identified by cluster analysis in discovery cohort. Group 1 (17 patients) had low PdetQmax (14 cmH2O), high maximal UFR (23.5 ml/s), and short voiding time (10.5 seconds). Group 2 (13 patients) had high PdetQmax (27 cmH2O), medial maximal UFR (14.4 ml/s), and short voiding time (10.6 seconds). Group 3 (8 patients) had low PdetQmax (7 cmH2O), low maximal UFR (11.4 ml/s), and long voiding time (26.1 seconds). We found that all DU (4 patients) and acontratile detrusor (AcD) (4 patients) patients were clustered in Group 3. In validation cohort, we assigned each data point to the nearest centroid (by Euclidean distance after standardization) of the groups that we obtained from the discovery cohort. We found that 7 of 8 DU or AcD patients in validation cohort were assigned to the Group 3. The positive predictive value and the negative predictive value of this approach for diagnosis of DU or AcD were 87.5% and 97.1%. Besides, we also used the validation cohort to repeat the cluster analysis. We discovered that we were able to replicate the division into three similar groups as the discovery cohort, and the centroids were almost the same. CONCLUSIONS: Among woman who had weak stream without BOO on VUDS, we detected three urodynamic characters, similarly in two independent patient cohorts, by using cluster analysis. The DU and AcD could be clustered into one of the groups with high sensitivity and specificity. We propose to use this cluster classification to identify DU on the daily practice. Source of Funding: Nil © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e31 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jen-Chieh Chen More articles by this author Chi-Chieh Lin More articles by this author Yu-Hua Fan More articles by this author Shing-Hwa Lu More articles by this author Alex T. L. Lin More articles by this author William J. Huang More articles by this author Expand All Advertisement PDF downloadLoading ...

The role of transurethral resection of prostate (TURP) in patients with underactive bladder: 12 months follow‐up in different grades of detrusor contractility

Male detrusor underactivity (DUA) definition remains controversial and no effective treatment is consolidated. Transurethral resection of the prostate (TURP) is one of the cornerstones surgical treatments recommended in bladder outlet obstruction (BOO). However, the role of prostatic surgery in male DUA is not clear. The primary endpoint was the clinical and voiding improvement based on IPSS and the maximum flow rate in uroflowmetry (Qmax) within 12 months. We analyzed an ongoing prospective database that embraces benign prostata hyperplasia (BPH) male patients with lower urinary tract symptoms who have undergone to TURP. All patients were evaluated pre and postoperatively based on IPSS questionnaires, prostate volume measured by ultrasound, postvoid residual urine volume (PVR), Prostate Specific Antigen measurement and urodynamic study (UDS) before the procedure. After surgery, all patients were evaluated at 1-, 3-, 6- and 12-months. Patients were categorized in 3 groups: Group 1-Detrusor Underactive (Bladder Contractility Index (BCI) [BCI] < 100 and BOO index [BOOI] < 40); Group 2-Detrusor Underactive and BOO (BCI < 100 and BOOI ≥ 40); Group 3-BOO (BCI ≥ 100 and BOOI ≥ 0). It was included 158 patients underwent monopolar or bipolar TURP since November 2015 to March 2021. According to UDS, patients were categorized in: group 1 (n = 39 patients); group 2 (n = 41 patients); group 3 (n = 77 patients). Preoperative IPSS was similar between groups (group 1-24.9 ± 6.33; group 2-24.8 ± 7.33; group 3-24.5 ± 6.23). Qmax was statistically lower in the group 2 (group 1-5.43 ± 3.69; group 2-3.91 ± 2.08; group 3-6.3 ± 3.18) as well as greater PVR. The 3 groups presented similar outcomes regard to IPSS score during the follow-up. There was a significant increase in Qmax in the 3 groups. However, group 1 presented the lowest Qmax improvement. There were different objective outcomes depending on the degree of DUA at 12 months follow-up. Patients with DUA had similar IPSS improvement. However, DUA patients had worst Qmax improvement than men with normal bladder contraction.

Urethral Sphincter Botulinum Toxin A Injection for Non-Spinal Cord Injured Patients with Voiding Dysfunction without Anatomical Obstructions: Which Patients Benefit Most?

Treating voiding dysfunction without anatomical obstructions is challenging. Urethral onabotulinum toxin A (BoNT-A) is used in treating voiding dysfunction; however, the success rate varies widely, and patients may not be satisfied with the treatment outcome. This study compared the efficacy of the urethral BoNT-A injection between patients with different non-spinal cord injury (SCI) voiding dysfunctions. This study retrospectively analyzed patients with refractory voiding dysfunction, including detrusor underactivity (DU), dysfunctional voiding (DV), and poor relaxation of the external sphincter (PRES) who received the urethral sphincter 100 U BoNT-A injection. The treatment outcomes were assessed via a global response assessment (GRA) one month after treatment. Baseline and follow-up videourodynamic study (VUDS) parameters were also compared. Totally, 161 patients (60 with DU, 77 with DV, and 24 with PRES) with a mean age of 58.8 ± 20.2 were enrolled, of which 62.1% had a good response (GRA ≥ 2) after urethral BoNT-A injection. DV patients had a higher success rate (76.6%) than DU (50%) and PRES (45.8%) patients (p = 0.002). A diagnosis of DV, higher voided volume and recurrent urinary tract infection were predictors of a good treatment response, while the cervical cancer status post-radical surgery predicted a poor response. Receiver operating characteristic (ROC) curve analyses identified PVR > 250 mL as a negative predictor (p = 0.008) in DU patients. The urethral BoNT-A injection provides a satisfactory success rate for non-SCI voiding dysfunction. Patients with DV benefit most from both subjective and objective parameters. Approximately 50% of patients with DU and PRES also had a fair response. PVR > 250 mL was a negative predictor in DU patients.

Therapeutic outcome of active management in male patients with detrusor underactivity based on clinical diagnosis and videourodynamic classification

Detrusor underactivity (DU) could be resulted from many different etiologies. Patients with DU might have reduced bladder sensation, low detrusor contractility, and large post-void residual volume. This study analyzed therapeutic outcome of active management for male DU patients, based on clinical and urodynamic characteristics. Male DU patients aged > 18 years old were retrospectively reviewed from the videourodynamic study (VUDS) records in recent 10 years. The patients’ demographics, VUDS results, treatment modalities, and treatment outcome were analyzed. The treatment outcomes were compared among patients with different DU subgroups, clinical diagnosis and treatment modalities. Patients with voiding efficiency of > 66.7% were considered having a successful treatment outcome. For comparison, 30 men with normal VUDS finding served as the control arm. Most of the DU patients had reduced bladder sensation. The reduced bladder sensation is closely associated with low detrusor contractility. After active treatment, a successful outcome was achieved in 68.4% of patients after bladder outlet surgery, 59.1% after urethral botulinum toxin A injection, and 57.6% after medical treatment, but only 18.2% after conservative treatment. A successful treatment outcome was achieved in patients with an intact detrusor contractility, either low (69.2%) or normal voiding pressure (81.8%), and in patients with a normal or increased bladder sensation (78.1%). However, patients with detrusor acontractile (41.3%) or absent bladder sensation (17.9%) had less favorable treatment outcome after any kind of urological management. This study revealed that active management can effectively improve voiding efficiency in patients with DU. The normal bladder sensation, presence of adequate detrusor contractility, and bladder outlet narrowing during VUDS provide effective treatment strategy for DU patients. Among all management, BOO surgery provides the best treatment outcome.

Correlations between bladder wall thickness and clinical manifestations in female patients with detrusor underactivity and detrusor overactivity-with-detrusor underactivity.

Among female patients with lower urinary tract symptoms, detrusor underactivity (DU), and detrusor overactivity-with-detrusor underactivity (DO-DU) are two common diagnoses. Here, we investigated the correlations between bladder wall thickness (BWT) and clinical manifestations of the two diagnoses. From 2011 to 2016, female patients with DU or DO-DU, diagnosed at our institute, were recruited. We analyzed their urodynamic parameters and collected three questionnaires (IPSS, UDI-6, OABSS). Using transabdominal sonography, the BWT was recorded. DU was defined as follows: maximum free flow rate (Qmax) ≤ 15 cc/s; detrusor pressure at maximum flow (PdetQmax) ≤ 20 cmH2O; bladder capacity > 150 cc. DO-DU was defined as follows: Qmax ≤ 15 cc/s; PdetQmax ≤ 20 cmH2O; bladder capacity ≤ 150 cc. The BWTs of the two groups were compared using the Mann-Whitney U test; the correlations among the BWTs and the results of three questionnaires were analyzed using Spearman's rank correlation coefficient. Forty-eight female patients with DU and 13 with DO-DU were recruited. Demographic data revealed no differences between the two groups. The mean BWT of the DO-DU patients was significantly larger than that of the DU patients (4.11 vs 3.42 mm; p = 0.001). In the DO-DU group, a high correlation existed between the BWT and some of the UDI-6 items (urgency incontinence: r = 0.831, p = 0.006; incontinence related to activity: r = 0.884, p = 0.002; small amounts of leakage: r = 0.809, p = 0.008). The BWT of the DO-DU patients also exhibited a moderate correlation with the urgency incontinence from the OABSS questionnaire (r = 0.679; p = 0.044). No correlations existed between the BWT of the DU patients and any of the data from the three questionnaires. The BWT in the DO-DU patients was significantly thicker than that in the DU patients. The DO-DU patients with thicker bladder walls also had higher UDI-6 scores for both urgency and urgency incontinence.

High percentage of neurologic deficits in the electrophysiology study of the lower urinary tract in patients with detrusor underactivity and chronic urinary retention.

Both detrusor underactivity (DU) and bladder outlet obstruction are the common causes of chronic urinary retention. Some novel treatment approaches focus on modulating micturition reflex and external urethral sphincter (EUS) function. This study used electrophysiologic (EP) studies to investigate the micturition reflex and EUS conditions of chronic urinary retention patients. Sixty patients with urodynamic DU and chronic urinary retention were studied using (1) bulbocavernous reflex (BCR) by electric stimulation, (2) electromyography (EMG) of the EUS, and (3) nerve conduction velocity (NCV) studies of the pudendal nerve. The EP findings were analyzed in DU patients with different etiologies. The BCR was positive in 41.7% of patients. In EMG studies, denervation, reinnervation, and reduced recruitment of the EUS were observed in 21.7%, 71.7%, and 88.3% patients, respectively. Decreased amplitude of pudendal nerve conduction in NCV studies was noted in 73.3% of patients. Patients with sacral neuropathy had a lower BCR positive rate (p = 0.001), a nonsignificant but higher denervation rate (p = 0.059) in EMG studies, and a higher rate of decreased amplitude in NCV (p = 0.011) than those without sacral neuropathy. Excluding patients with sacral neuropathy or diabetes mellitus, a high percentage of neurologic deficits was still detected in EP studies. Chronic urinary retention patients with urodynamic DU not only have bladder dysfunction, but also potential neuropathy in the sacral reflexes, pudendal nerve, or urethral sphincter innervation. The neurologic deficits explored in EP studies may affect the decision-making around the therapy to restore the voiding function in DU.

Impact of detrusor underactivity on the postoperative outcomes after benign prostatic enlargement surgery.

Previous studies suggest that men with detrusor underactivity (DUA) have less symptomatic improvement after prostate surgery than those with normal contractility, but the available data is controversial. We aim to determine the differences in functional outcomes of patients with or without DUA who underwent photovaporization of the prostate (PVP) with GreenLight™180 W XPS. A cohort of patients with lower urinary tract symptoms (LUTS) who underwent PVP between 2012 and 2019 was evaluated. Patients were stratified according to bladder contractility index (BCI). DUA was defined as BCI < 100. Those with normal contractility (BCI = 100-150) were included in Group 1, and those with DUA (BCI < 100) in Group 2. Primary outcomes were symptomatic improvement defined as a reduction ≥ 4 points in the international prostate symptom score (IPSS) and a reduction of at least 1 point in the quality of life (IPSS-QoL). Complications according to the Clavien-Dindo classification were also recorded. A total of 271 patients who underwent PVP with GreenLight™ and met the inclusion criteria were assessed. Group 1 included 158 patients, while Group 2 included 113 patients. Mean follow-up was 24 months. Patients with normal contractility had a median reduction of 11 points (18.9 ± 8.0 to 7.1 ± 7.0) while patients with DUA had a median reduction of 10 points (19.3 ± 6.9 to 8.6 ± 8.4) in IPSS score; these differences were not statistically significant (p = .20). Patients in Group 1 had a 1.92 higher chance of QoL improvement (OR, 1.92; 90% CI, 1.10-3.37), compared to those in Group 2. Failure to void after PVP was most frequently reported in DUA patients (OR, 2.36; 90% CI, 1.26-4.43). Sociodemographic characteristics, intraoperative complications, conversion rates, hospital stay, and urinary catheterization time were similar between groups. Patients with LUTS, regardless of their BCI, improved their symptoms after PVP according to the IPSS. However, patients with DUA were more likely not to improve their QoL after the procedure and had a higher chance of failure to void in the immediate postoperative period. An appropriate counseling process with the patient discussing possible outcomes based on these findings should be encouraged.

The role of bladder wall thickness in the evaluation of detrusor underactivity: Development of a clinical nomogram.

The aim of our study was to investigate noninvasive predictors for detrusor underactivity (DUA) in male patients with lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE). A consecutive series of patients aged 45 years or older with non-neurogenic LUTS were prospectively enrolled. Patients underwent standard diagnostic assessment including International Prostatic Symptoms Score, uroflowmetry, urodynamic studies (cystometry and pressure-flow studies), transrectal ultrasound of the prostate, and ultrasound measurements of the bladder wall thickness (BWT). Logistic regression analysis was used to investigate predictors of DUA, defined as a bladder contractility index < 100 mm H2 O. A nomogram was developed based on the multivariable logistic regression model. Overall 448 patients with a mean age of 66 ± 11 years were enrolled. In a multivariable logistic age-adjusted regression model BWT (odds ratio [OR]: 0.50 per mm; 95% confidence interval [CI], 0.30-0-66; P = .001) and Qmax (OR: 0.75 per mL/s; 95% CI, 0.70-0.81; P = .001) were significant predictors for DUA. The nomogram based on the model presented good discrimination (area under the curve [AUC]: 0.82), good calibration (Hosmer-Lemeshow test, P > .05) and a net benefit in the range of probabilities between 10% and 80%. According to our results, BWTand Qmax can noninvasively predict the presence of DUA in patients with LUTS and BPE. Although our study should be confirmed in a larger prospective cohort, we present the first available nomogram for the prediction of DUA in patients with LUTS.

Novel symptom questionnaire for the differential diagnosis of detrusor underactivity and bladder outlet obstruction in men

Objective: To develop a questionnaire for the differential diagnosis of detrusor underactivity (DUA) and bladder outlet obstruction (BOO) without performing invasive pressure flow studies.Study design and methods: Symptoms of men with DUA were analyzed and compared with those of men with BOO using eight questions from the developing questionnaire. Patients with DUA have a bladder contractility index (PdetQmax+5xQmax) less than 100, whereas those with BOO have a BOO index (PdetQmax−2xQmax) greater than 40 in urodynamic studies (UDS). Men with detrusor overactivity in UDS and neurogenic issues were excluded from the analysis. One urologist reviewed patients’ medical records, and responded to eight questions without using information from UDS. Scores in the developing questionnaire were then compared to make a differential diagnosis between DUA and BOO.Results: Overall, 318 men who underwent UDS were included. Symptoms were compared in patients diagnosed with DUA without BOO (n = 165) and BOO without DUA (n = 153). Questions 1, 2, 4, 5, 6, and 7 were significantly different between groups. The sensitivity and specificity of the questionnaire were 95.8% and 95.4%, respectively, for predicting DUA in patients with scores greater than 45 points (cutoff value).Conclusions: Men with DUA and BOO may be distinguished using a developing questionnaire without invasive evaluation. Men with scores greater than 45 points would be expected to have DUA but not BOO.

What are the additional signs and symptoms in patients with detrusor underactivity and coexisting detrusor overactivity?

This study aimed to determine what difference the inclusion of patients with coexisting detrusor overactivity (DO) makes to the signs and symptoms of patients with detrusor underactivity (DU). A total of 250 male and 435 female urodynamic tests were analyzed retrospectively. Signs and symptoms which showed a statistically significant difference between DU without DO and DU with DO were identified. Males with DO in addition to DU had higher age and number of daily micturitions, and were more likely to report urgency with or without urgency incontinence than males with DU without DO. They also had lower volumes for first desire to void, volume voided, and post void residual urine, lower abdominal pressure at Qmax and were less likely to report a history of retention or reduced bladder filling sensation than males with DU without DO. Females with DO in addition to DU had higher age and BMI, and were more likely to report urgency incontinence, higher day and night pad usage, constipation and have reduced anal tone than females with DU without DO. They also had lower volumes for first desire to void, volume voided, and post void residual urine, and lower abdominal pressure at Qmax than females who had DU without DO. There are differences in signs and symptoms between patients who have DU without DO, compared to patients having DU with DO. This understanding will help future studies investigating treatment options for DU patients.

Detrusor underactivity in pelvic organ prolapse.

The association between pelvic organ prolapse (POP) and detrusor underactivity (DU) is not well defined. The primary outcome of this study was to evaluate the prevalence of DU in a cohort of patients with POP and its association with symptoms, anatomy. and urodynamic findings. The secondary outcome was to evaluate the evolution of lower urinary tract symptoms after POP repair between DU and non-DU patients. Consecutive patients who underwent preoperative urodynamic tests were retrospectively analyzed. Detrusor underactivity was evaluated by the Bladder Contractility Index (BCI = pDetQmax + Qmax × 5) proposed by Abrams. A BCI < 100 was considered indicative of an underactive bladder. Patients with underactive bladder were considered group A, whereas the remaining patients were classified as group B. A total of 518 patients were studied. According to BCI, detrusor underactivity was identified in 212 (40.9%) patients (group A). Group A showed higher rates of voiding symptoms (59.4% vs 36.3%, p < 0.0001) and positive (>100ml) postvoid residual (29.7% vs 9.8%, p < 0.0001). Conversely, they displayed lower rates of urge incontinence (15.1% vs 23.2%, p = 0.02) and detrusor overactivity (15.6% vs 23.9%, p = 0.02). Preoperative Pelvic Organ Prolapse Quantification (POP-Q) demonstrated greater Aa (+1.1 ± 1.5 vs +0.9 ± 1.5, p = 0.03) and Ba (+1.4 ± 1.7 vs +1.2 ± 1.7, p = 0.04) points values in patients in group A. After POP surgery, postoperative voiding symptoms were similar in the two groups (16% vs 15.7%, p = 0.91). Our study showed a 40.9% prevalence of DU in POP patients. DU was associated with the presence of voiding symptoms and positive PVR. Moreover, cystocele showed to be more severe in DU group. After surgical repair of POP, voiding symptoms of DU patients became equal to non-DU ones, suggesting that obstruction removal might recover DU in these patients.

Impact of detrusor underactivity on the outcomes of transurethral resection of prostate in patients with benign prostatic obstruction

Objective To analyze the impact of detrusor underactivity(DU) on the outcomes of transurethral resection of prostate (TURP) in patients with benign prostatic obstruction(BPO). Methods A retrospective study was conducted in 157 BPO patients who underwent TURP from January 2013 to December 2016.Their ages ranged from 48 to 86 years with a mean age of 70 years. All patients underwent urodynamic study before surgery, bladder contraction index(BCI) ranged from 49.3 to 208.6, with a mean of 120.1. The patients were divided into two groups according to BCI. DU group(BCI 0.05 for each). The outcomes of TURP were assessed by the above mentioned parameters at 3 months postoperatively; IPSS、IPSS-S、IPSS-V were regarded as successful if they improved more than 50%, QOL was successful if it was improved more than 3, fQmax successful if it was improved 5ml/s.The change and successful improvement rates of the above mentioned parameters were compared between DU and non-DU group. Through receiver operating characteristic curve(ROC) analysis , patients were categorized into mild DU and severe DU group and compared the successful improvement rates between the two groups. Results Both DU group and non-DU group improved significantly in IPSS, IPSS-S, IPSS-V, QOL, fQmax, PVR at 3 months postoperatively(P 0.05 for each]. Conclusions Benign prostatic obstruction patients with DU can achieve improvement in both subjective and objective parameters after TURP, but patients without DU can get more improvement. BPO patients with severe DU patients show a worse improvement of the voiding symptom. Surgeons should have adequate communication with the patients and inform them of appropriate expectations. Key words: Benign prostatic obstruction; Transurethral resection of prostate; Urodynamics; Bladder contraction index; Detrusor underactivity

Urinary biomarkers in patients with detrusor underactivity with and without bladder function recovery.

Detrusor underactivity (DU) is frequently encountered in elderly patients. Part of patients with DU might have bladder function recovery after treatment. This study investigated urinary proteins in these DU patients with and without bladder function recovery. A total of 37 patients with chronic urinary retention and urodynamically proven DU were enrolled. After treatment, 24 DU patients had bladder function recovery whereas 13 had not, after 1-year follow-up. Urine collection at baseline was performed, and the urinary protein including nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF) and prostaglandin E2 (PGE2) were measured by ELISA. Twenty urodynamically normal, 34 detrusor overactivity (DO) and 15 detrusor hyperactivity and inadequate contractility (DHIC) patients served as comparative groups. Urinary NGF levels were significantly higher than normal in patients with DU (9.2±20.3 vs 1.85±2.9pg/ml, p=0.037). Urinary BDNF level was only significantly higher in patients with DU than that of the control group (153±199 vs 77.4±47.7pg/ml, p=0.033) but not in patients with DHIC or DO. Compared with the control group, the urinary BDNF level was significantly higher in DU patients with bladder function recovery (190±239pg/ml, p=0.033) but not in patients without recovery (85.8±43.7pg/ml, p=0.612). The PGE2 level was significantly higher than the control group in DU patients with bladder function recovery (1290±836pg/ml, p<0.0001) but not in patients without recovery (383±237pg/ml, p=0.130). Patients with DU and higher urinary PGE2 and BDNF levels might have a chance to recover bladder function than those with a lower protein level.

Video-urodynamic characteristics of non-neurogenic, idiopathic underactive bladder in men - A comparison of men with normal tracing and bladder outlet obstruction.

ObjectiveUnderactive bladder is frequently encountered in elderly patients. It may result from detrusor underactivity (DU) or low detrusor contractility due to a urethral sphincter inhibitory effect. This study analyzed the video-urodynamic study (VUDS) characteristics of patients with underactive bladder in a large cohort of men with lower urinary tract symptoms (LUTS).MethodsMale patients with LUTS who had failed the initial treatment were consecutively enrolled. All patients underwent detailed urological investigations including prostate measurement, free uroflowmetry, post-void residual volume (PVR) measurement, cystoscopy and VUDS. The VUDS characteristics of the men with underactive bladder were analyzed and compared with those of men with bladder outlet obstruction and normal tracing.ResultsA total of 1329 men who underwent VUDS were included in this retrospective analysis. After VUDS, the final diagnosis was DU in 165 patients, poor relaxation of external sphincter (PRES) in 525, bladder outlet obstruction in 501, and normal tracing in 138. VUDS findings in DU patients showed a slowly increased detrusor pressure, intermittent detrusor contractions, or early decline of detrusor contraction, resulting in a low maximum flow rate (Qmax), and large PVR. In comparison with the PRES groups, DU patients were older, had reduced bladder sensation, lower detrusor pressure (Pdet), lower Qmax, larger PVR volume, and lower voiding efficiency. Patients with urodynamic PRES also had low-pressure–low-flow tracings, but their bladder sensation was similar to that with normal tracing. DU patients with very low Pdet also had low detrusor tonicity, and more medical co-morbidities than the other groups did.ConclusionIdiopathic underactive bladder in elderly men could be attributed to urodynamic DU and PRES. DU is associated with old age, reduced bladder sensation, low voiding efficiency, and medical co-morbidities.

MP27-04 GIVING UNDERACTIVE BLADDERS A SECOND CHANCE: HOLMIUM LASER ENUCLEATION OF THE PROSTATE FOR MANAGEMENT OF LOWER URINARY TRACT SYMPTOMS IN PATIENTS WITH DETRUSOR UNDERACTIVITY.

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology II1 Apr 2017MP27-04 GIVING UNDERACTIVE BLADDERS A SECOND CHANCE: HOLMIUM LASER ENUCLEATION OF THE PROSTATE FOR MANAGEMENT OF LOWER URINARY TRACT SYMPTOMS IN PATIENTS WITH DETRUSOR UNDERACTIVITY. Garrett Smith, Dongliang Wang, and Jessica E. Paonessa Garrett SmithGarrett Smith More articles by this author , Dongliang WangDongliang Wang More articles by this author , and Jessica E. PaonessaJessica E. Paonessa More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.796AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Lower urinary tract symptoms (LUTS) in men are classically attributed to bladder outlet obstruction (BOO). However, LUTS may also exist in the presence of detrusor underactivity (DU). Evaluation of the voiding phase in patients with BOO demonstrates high bladder pressures and low flow rates. In contrast, low bladder pressures and low flow rates are characteristic of patients with DU. Holmium laser enucleation of the prostate (HoLEP) has been shown to be a safe, durable and effective surgical treatment for BOO secondary to benign prostatic enlargement (BPE) in prostates of any size. In our early experience, we have identified a population of patients with DU and BPE who have benefitted from HoLEP. We compared patients with BOO to those with DU to determine if outcomes after HoLEP are comparable. METHODS Our HoLEP database was retrospectively reviewed, identifying 84 patients with preoperative (preop) urodynamic studies (UDS) who underwent HoLEP with or without bladder neck incision (+/- BNI). Of these patients, 24 had UDS consistent with DU; defined as max flow rate (Qmax) < 15 ml per second and detrusor pressure (Pdet) < 40 cm water. The remaining 60 patients had BOO (Qmax < 15 and Pdet ≥ 40). International Prostate Symptom Score and Sexual Health Inventory for Men questionnaires were administered preop and at each postoperative (postop) visit. All surgeries were performed by a single surgeon, supervising residents, from December 2014 to September 2016. RESULTS There were no differences (p > 0.05) in patient demographics, catheter dependence, preop questionnaires and incontinence, enucleation/morcellation time, tissue volume removed and length of hospital stay between the two groups. Patients with DU had higher preop post void residual (PVR) (p = 0.017) and lower Qmax (p = 0.007). There were no differences in postop questionnaires and incontinence at 6 weeks, 6 months (mo) and 12 mo. PVRs were higher in DU patients at 6 weeks (p = 0.012), but not at 6 and 12 mos. All patients were able to void after HoLEP. One patient with DU was self catheterizing once nightly at 6 mo follow up. CONCLUSIONS The standard treatment for patients with DU and urinary retention is catheterization (clean intermittent or chronic indwelling). Typically, these patients are not offered surgery. For patients who can Valsalva and stand to void, HoLEP +/- BNI may improve quality of life and allow them to be catheter free. These findings may also support expanding the indications for HoLEP. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e329 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Garrett Smith More articles by this author Dongliang Wang More articles by this author Jessica E. Paonessa More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD26-11 SYMPTOMS AND NONINVASIVE PARAMETERS THAT PREDICT DETRUSOR UNDERACTIVITY IN MEN WITH LOWER URINARY TRACT SYMPTOMS: AN ANALYSIS USING A LARGE GROUP OF PATIENTS UNDERGOING PRESSURE FLOW STUDY

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Non-neurogenic Voiding Dysfunction II1 Apr 2017PD26-11 SYMPTOMS AND NONINVASIVE PARAMETERS THAT PREDICT DETRUSOR UNDERACTIVITY IN MEN WITH LOWER URINARY TRACT SYMPTOMS: AN ANALYSIS USING A LARGE GROUP OF PATIENTS UNDERGOING PRESSURE FLOW STUDY Ryo Namitome, Mineo Takei, Ryosuke Takahashi, Tomoko Maki, Ken Lee, Shunichi Kajioka, Akito Yamaguchi, and Masatoshi Eto Ryo NamitomeRyo Namitome More articles by this author , Mineo TakeiMineo Takei More articles by this author , Ryosuke TakahashiRyosuke Takahashi More articles by this author , Tomoko MakiTomoko Maki More articles by this author , Ken LeeKen Lee More articles by this author , Shunichi KajiokaShunichi Kajioka More articles by this author , Akito YamaguchiAkito Yamaguchi More articles by this author , and Masatoshi EtoMasatoshi Eto More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1219AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Underactive bladder (UAB) is a symptom complex suggestive of detrusor underactivity (DU). However, DU can be diagnosed at present only on the basis of an invasive pressure flow study (PFS), which has hampered the development of clinical research and effective treatment for UAB. Noninvasive diagnostic approaches for DU could potentially facilitate the diagnosis and research of this field. We therefore investigated to identify the noninvasive predictive factors for DU using a large group of patients undergoing PFS. METHODS We reviewed 2838 male patients who underwent PFS for lower urinary tract symptoms (LUTS). Age, International Prostate Symptom Score (IPSS), post-void residual volume (PVR), prostate volume (PV), and PFS parameters were obtained and analyzed. DU was defined as bladder contractility index <100. A multivariate logistic regression model was used to identify the factors associated with DU. RESULTS Of the patients, 1355 patients (46%) were classified as having DU. In univariate analysis, the prevalence of DU was significantly increased with increasing age (P<0.001) and PVR elevation (P<0.001), but decreased with increasing PV (P<0.001). The assessment of subjective symptoms using IPSS questionnaire revealed that patients with DU had a statistically significant higher occurrence of frequency (P=0.01), intermittency (P=0.001) and weak stream (P=0.01) compared with non-DU patients. On the other hand, the occurrence of urgency symptom (P<0.001) was significantly lower in DU patients. In multivariate analysis, increasing age, PVR elevation, small PV, and several symptoms including frequency, intermittency, weak stream and urgency were selected as predictive factors for DU. CONCLUSIONS Several symptoms (frequency, intermittency, urgency and weak stream), increasing age, PVR elevation and small PV could be predictive factors of male DU. Combined evaluation of these factors might be useful for the diagnosis and better understanding of the clinical presentation of male DU. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e510 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Ryo Namitome More articles by this author Mineo Takei More articles by this author Ryosuke Takahashi More articles by this author Tomoko Maki More articles by this author Ken Lee More articles by this author Shunichi Kajioka More articles by this author Akito Yamaguchi More articles by this author Masatoshi Eto More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

OnabotulinumtoxinA Urethral Sphincter Injection as Treatment for Non-neurogenic Voiding Dysfunction - A Randomized, Double-Blind, Placebo-Controlled Study.

Non-neurogenic voiding dysfunction including dysfunctional voiding and detrusor underactivity caused by a spastic or non-relaxing external urethral sphincter can theoretically be treated by injections of botulinum A toxin into the external urethral sphincter. This randomized, double-blind, placebo-controlled trial was designed to determine the clinical efficacy of onabotulinumtoxinA urethral sphincter injections in patients with dysfunctional voiding or detrusor underactivity. Patients with medically refractory dysfunctional voiding (n = 31) or detrusor underactivity (n = 31) were randomly allocated in a 2:1 ratio to receive either onabotulinumtoxinA (100 U) (n = 38) or placebo (normal saline) (n = 24). There were no significant differences in subjective or objective parameters between patients who received onabotulinumtoxinA and those who received saline injection therapy, and the overall success rate was 43.5% (reduction in Patient perception of Bladder Condition by ≥2: onabotulinumtoxinA 36.8% vs placebo 54.2%, p = 0.114). The results were similar between the dysfunctional voiding and detrusor underactivity subgroups; however, a significant reduction in detrusor voiding pressure was only observed in dysfunctional voiding patients who received onabotulinumtoxinA. Repeat urethral sphincter onabotulinumtoxinA injections offered greater therapeutic effects in both dysfunctional voiding and detrusor underactivity patients. For patients with non-neurogenic voiding dysfunction, the success rate of onabotulinumtoxinA urethral sphincter injection was not superior to placebo.