Incidence Of Detrusor Instability Research Articles

The Significance of Bladder Trabeculation in the Female Lower Urinary System: An Objective Evaluation by Urodynamic Studies

This study aimed to investigate the relationship between bladder trabeculation, urinary function, and the stage of pelvic organ prolapse (POP). The medical records of 104 patients with POP who underwent cystoscopies and urodynamic studies were reviewed retrospectively. Age, incidence of detrusor instability, stage and site of POP, and the parameters of urodynamic studies of patients with and without bladder trabeculation were compared. The difference in the incidence of bladder trabeculation was estimated between patients with and without a suspected bladder outlet obstruction. There were significant differences in the patients' age, stage of POP, and maximal voiding velocity. Patients with a suspected bladder outlet obstruction had a significantly higher incidence of bladder trabeculation. In addition, patients with advanced stages of POP were also found to have a higher incidence of bladder trabeculation.

A Randomized Controlled Trial Comparing Transurethral Resection of the Prostate, Contact Laser Prostatectomy and Electrovaporization in Men with Benign Prostatic Hyperplasia: Urodynamic Effects

We compared urodynamic and uroflowmetry improvements in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH) after transurethral prostate resection, contact laser prostatectomy and electrovaporization. A prospective randomized controlled trial was performed in men with lower urinary tract symptoms suggestive of BPH who met the criteria of the International Scientific Committee on BPH, had a prostate volume of between 20 and 65 ml., and a Schäfer obstruction grade of 2 or greater. Before and 6 months after treatment urodynamics and free uroflowmetry were performed. A total of 50, 45 and 46 men were randomized to transurethral prostate resection, laser treatment and electrovaporization, respectively. Baseline characteristics were similar in the 3 groups. Detrusor contractility did not change in any of the treatment groups. The average maximum free flow rate increased by a factor of 2.4 after transurethral prostate resection, 2.5 after laser prostatectomy and 2.4 after electrovaporization. The Schäfer obstruction grade decreased by a factor of 0.3 in all groups. Obstruction (Schäfer grade greater than 2) was not noted after transurethral prostate resection or electrovaporization but it was evident in 2 patients after laser prostatectomy. Effective capacity increased by a factor of 1.5 or more. The incidence of detrusor instability was decreased by half in all groups. The incidence of significant post-void residual urine volume decreased in all groups. There were no significant differences in the improvement in urodynamic and uroflowmetry parameters 6 months after treatment when comparing transurethral prostate resection, contact laser prostatectomy and electrovaporization in men with lower urinary tract symptoms suggestive of BPH.

URODYNAMIC FINDINGS IN BOYS WITH POSTERIOR URETHRAL VALVES AFTER TREATMENT WITH PRIMARY VALVE ABLATION OR VESICOSTOMY AND DELAYED ABLATION

Primary valve ablation and temporary vesicostomy with delayed valve ablation are alternative initial management procedures in neonates and infants with posterior urethral valves. To investigate whether initial vesicostomy followed by delayed valve ablation and simultaneous vesicostomy closure may lead to more alterations in bladder function than primary valve ablation only we retrospectively compared postoperative urodynamic findings in 2 small groups of patients. From 1980 to 1990, 15 male infants 19 days to 34 months old with posterior urethral valves were treated with 1 of 2 initial surgical approaches, including valve ablation only in 8 (group 1), and primary vesicostomy and delayed valve ablation associated with concomitant vesicostomy closure in 7 (group 2). Mean age at valve ablation and vesicostomy in groups 1 and 2 was 10.8 +/- 11.2 months (range 1 to 35) and 55.4 +/- 43.3 days (range 19 to 151), respectively. Average duration of vesicostomy diversion was 33.6 +/- 18.8 months (range 14 to 70). All patients underwent conventional urodynamics postoperatively using normal saline at room temperature. In groups 1 and 2 mean age at followup was 11.5 +/- 6.6 (range 5 to 16.2) and 9. 4 +/- 3.1 (range 4.10 to 14) years, respectively. Controls comprised 46 age matched males who underwent urodynamics using similar methodology. Postoperative urodynamic assessment of maximum cystometric bladder capacity and the incidence of detrusor instability in each treatment group were not statistically different. In group 1 bladder capacity was significantly higher than that in controls (p <0.0001). In group 2 mean end filling detrusor pressure was increased compared with that in group 1 (29 cm. water, range 15 to 60 versus 8, range 4 to 21). Compliance was significantly lower in group 2 than in group 1 (p <0.0005). Analysis of detrusor voiding pressure at maximum flow was not significantly different in the 2 groups. We noted detrusor under activity in 1 group 1 and 2 group 2 cases. In these patients post-void residual urine volume was 8% to 66% of cystometric bladder capacity. However, only 1 of these 3 patients who required augmentation cystoplasty needed intermittent catheterization. Urodynamic patterns of outflow obstruction developed in 1 patient in each group, including urethral stricture and bladder neck obstruction. At followup we observed no difference in renal function impairment in the 2 groups. Our retrospective study of rapid filling cystometry suggests that primary valve ablation for posterior urethral valves is associated with a better bladder function outcome than that in patients treated with vesicostomy and delayed valve ablation. Therefore, although cutaneous vesicostomy may be performed as initial management of posterior urethral valves, primary valve ablation is the most effective surgical option in these cases.

The incidence of detrusor instability before and after colposuspension: a study using conventional and ambulatory urodynamic monitoring.

To determine the incidence of detrusor instability (DI) detected by conventional and ambulatory bladder pressure monitoring, any link between urodynamic findings before and after colposuspension, and between patients' symptoms and the urodynamic findings. Sixty-five patients, scheduled to undergo colposuspension on the basis of pure genuine stress incontinence on conventional cystometrography (CMG), also underwent ambulatory monitoring (AM) before surgery. All were requested to return 3 months afterward for repeat CMG and AM in random order. In all, 56 patients completed all assessments before and after surgery. In addition to the urodynamic assessment, the patients' symptoms before and after surgery were compared using a detailed questionnaire. On AM before surgery, half the patients showed some DI; afterward, the incidence on AM was 70% and on CMG was 27%. However, on AM, 25% of patients who had DI before surgery showed no evidence of it afterward. Of the 19 women who complained of urgency preoperatively, 16 showed DI on preoperative AM. However, of the 37 women denying urgency preoperatively, 12 (32%) also showed evidence of DI on preoperative AM. There is a significant incidence of DI detected by CMG after colposuspension in patients who are stable before surgery. The incidence of DI on AM was significantly higher than on CMG both before and after surgery. However, the preoperative urodynamic finding of increased DI on AM does not exclusively predict its presence postoperatively on AM or CMG. In addition, a patient history of urgency does not correlate well with the urodynamic findings before or after surgery. Therefore, from this study it appears that the postoperative symptomatic or urodynamic state cannot be predicted reliably from those before surgery.

DIAGNOSING BLADDER OUTLET OBSTRUCTION IN WOMEN

There are no universally accepted urodynamic criteria for diagnosing female bladder outlet obstruction. When accepted criteria for men are applied to women, the diagnosis of obstruction may often be missed, which is most likely due to differences in voiding dynamics. We propose video urodynamic criteria for diagnosing obstruction in women, and describe the urodynamic findings in those with and without obstruction. We reviewed the charts of 331 women who underwent multichannel video urodynamics for nonneurogenic voiding dysfunction. Of these women 261 (mean age 55.8 years) had evaluable voiding pressure flow studies with simultaneous video fluoroscopy of the bladder outlet during voiding. At video urodynamics cases were classified as obstructed if there was radiographic evidence of obstruction between the bladder neck and distal urethra in the presence of a sustained detrusor contraction. Strict pressure flow criteria were not used. Maximum flow rate, detrusor pressure at maximum flow rate, post-void residual, bladder capacity and the incidence of detrusor instability were compared between obstructed and unobstructed cases. A total of 76 women met the criteria for obstruction (mean age 57.5 years), while 184 (mean age 55) did not. Causes of obstruction were dysfunctional voiding in 25 cases, cystocele in 21, primary bladder neck obstruction in 12, iatrogenic from incontinence surgery in 11, urethral stricture in 3, uterine prolapse in 2, urethral diverticulum in 1 and rectocele in 1. Obstructed cases had lower mean maximum flow rate (9 versus 20.2 ml. per second, p <0.0001), higher mean detrusor pressure at maximum flow rate (42.8 versus 22.1 cm. water, p <0.0001) and higher mean post-void residual (157 versus 33 ml., p <0.0001). There was no difference in bladder capacity (381 versus 347 ml.) or incidence of detrusor instability (45 versus 41%). Using the proposed video urodynamic criteria obstructed cases had significantly higher voiding pressures, lower flow rates and higher post-void residual than unobstructed cases, as expected. However, absolute values, especially for voiding pressure, are not as dramatic in women as in men. Pressure flow studies alone may fail to diagnose obstruction but simultaneous imaging of the bladder outlet during voiding greatly facilitates diagnosis.

The international prostate symptom score in both sexes: A urodynamics‐based comparison

The aim of our study was to determine the urodynamic basis for the observation that aging women report comparable benign prostatic hyperplasia (BPH) symptom scores as age-matched men. Sixty-seven women (mean age, 60.4 ± 1.5 years; mean ± standard error of the mean) and 70 age-matched men (mean age, 63.7 ± 0.9 years; P > 0.05) entered this prospective study. Men were referred for the diagnostic workup of lower urinary tract symptoms (LUTS) due to BPH and women predominantly for urinary incontinence. All patients completed the International Prostate Symptom score (IPSS) with quality-of-life assessment and underwent a detailed clinical and urodynamic evaluation including a multichannel pressure-flow study. Results of the IPSS, quality-of-life assessment, and irritative and obstructive component of the IPSS were correlated with urodynamic findings and the respective data were compared in both sexes. The mean IPSS was 15.7 for men and 13.0 for women (P = 0.02), quality-of-life score was higher in women (4.2 vs. 3.4; P = 0.0008). The irritative score was significantly higher in women (8.7 vs. 6.8; P = 0.003). Incidence of detrusor instability (DI), however, was higher in men (women, 38.1%; men, 48.6%; P = 0.015) and bladder capacity was higher in women (425 vs. 333 ml; P = 0.0001). There was no correlation between incidence and degree of DI with the irritative score in both sexes. The obstructive score was significantly higher in men (8.8 vs. 4.4; P = 0.0001). Ninety-one percent (64/70) of men had urodynamically documented bladder outlet obstruction (BOO), whereas this was the case in only 9% (6/67) of women. In parallel to the irritative score, we could not identify a correlation between the degree of urodynamically proven BOO and the obstructive score in both sexes. This urodynamics-based comparison fails to give an explanation for the observation that aging women report similar BPH scores as men. These data suggest that other mechanisms, such as changes in diurnal urine production, structural alterations of the aging detrusor, endocrine disturbances affecting lower urinary tract function, and subtle urodynamic changes are responsible. Neurourol. Urodynam. 18:173–182, 1999. © 1999 Wiley-Liss, Inc.

The international prostate symptom score in both sexes: A urodynamics-based comparison

The aim of our study was to determine the urodynamic basis for the observation that aging women report comparable benign prostatic hyperplasia (BPH) symptom scores as age-matched men. Sixty-seven women (mean age, 60.4 +/- 1.5 years; mean +/- standard error of the mean) and 70 age-matched men (mean age, 63.7 +/- 0.9 years; P > 0.05) entered this prospective study. Men were referred for the diagnostic workup of lower urinary tract symptoms (LUTS) due to BPH and women predominantly for urinary incontinence. All patients completed the International Prostate Symptom score (IPSS) with quality-of-life assessment and underwent a detailed clinical and urodynamic evaluation including a multichannel pressure-flow study. Results of the IPSS, quality-of-life assessment, and irritative and obstructive component of the IPSS were correlated with urodynamic findings and the respective data were compared in both sexes. The mean IPSS was 15.7 for men and 13.0 for women (P = 0.02), quality-of-life score was higher in women (4.2 vs. 3.4; P = 0.0008). The irritative score was significantly higher in women (8.7 vs. 6.8; P = 0.003). Incidence of detrusor instability (DI), however, was higher in men (women, 38.1%; men, 48.6%; P = 0.015) and bladder capacity was higher in women (425 vs. 333 ml; P = 0.0001). There was no correlation between incidence and degree of DI with the irritative score in both sexes. The obstructive score was significantly higher in men (8.8 vs. 4.4; P = 0.0001). Ninety-one percent (64/70) of men had urodynamically documented bladder outlet obstruction (BOO), whereas this was the case in only 9% (6/67) of women. In parallel to the irritative score, we could not identify a correlation between the degree of urodynamically proven BOO and the obstructive score in both sexes. This urodynamics-based comparison fails to give an explanation for the observation that aging women report similar BPH scores as men. These data suggest that other mechanisms, such as changes in diurnal urine production, structural alterations of the aging detrusor, endocrine disturbances affecting lower urinary tract function, and subtle urodynamic changes are responsible.

Urodynamic findings in postprostatectomy incontinence

Due to the large variability in the reported contribution of bladder dysfunction to postprostatectomy incontinence and the impact this dysfunction may have on the outcome of selected treatment, we retrospectively reviewed the videourodynamic findings of bladder and sphincteric function in patients with postprostatectomy incontinence. The contributions of bladder and sphincteric causes of incontinence are determined. Ninety-two patients had multichannel videourdynamic testing performed as part of a comprehensive evaluation for incontinence at least 1 year after prostatectomy. Using a 6-French double-lumen catheter in the bladder and a 10-French catheter in the rectum, all pressures were recorded continuously while in the upright position. Valsalva leak point pressures (VLPP) were measured in the absence of a bladder contraction at a 150-ml volume and at 50-ml increments thereafter until maximum functional capacity was reached. Bladder compliance and bladder capacity were determined and the presence of detrusor instability (DI) was documented. Sixty-five patients (71%) presented after radical prostatectomy (RP) and 27 patients (29%) after transurethral resection of the prostate (TURP). The predominant urodynamic finding was sphincteric incompetence as VLPP were obtained in 85 patients (92%) and ranged from 12 to 120 cm water. DI was a common finding, occurring in 34 patients (37%), and classified as follows: a) phasic instability in 22/34, b) tonic instability in 3/34, and c) mixed phasic and tonic instability in 9/34. However, we found DI to be the sole cause of incontinence in only 3/92 patients (3.3%). There was no statistically significant difference in the incidence of sphincteric incompetence after RP or TURP; however, TURP patients had a higher incidence of DI, which was statistically significant (P = 0.019). There was no correlation of incontinence severity and VLPP when comparing preoperative pad usage to VLPP ⩽70 or ⩾71 cm water. Although bladder dysfunction may be contributing problem in patients with postprostatectomy incontinence, it is rarely the only mechanism for this disorder. VLPP does not correlate with incontinence severity. Although sphincteric incompetence is the most common mechanism contributing to incontinence after prostatectomy, bladder dysfunction may coexist or be an isolated cause of postprostatectomy incontinence. Therefore, urodynamic studies are important to illustrate the exact cause(s) of incontinence in each individual patient after prostatectomy. Neurol. Urodynam. 17:493–498, 1998. © 1998 Wiley-Liss, Inc.

Urodynamic findings in postprostatectomy incontinence.

Due to the large variability in the reported contribution of bladder dysfunction to postprostatectomy incontinence and the impact this dysfunction may have on the outcome of selected treatment, we retrospectively reviewed the videourodynamic findings of bladder and sphincteric function in patients with postprostatectomy incontinence. The contributions of bladder and sphincteric causes of incontinence are determined. Ninety-two patients had multichannel videourdynamic testing performed as part of a comprehensive evaluation for incontinence at least 1 year after prostatectomy. Using a 6-French double-lumen catheter in the bladder and a 10-French catheter in the rectum, all pressures were recorded continuously while in the upright position. Valsalva leak point pressures (VLPP) were measured in the absence of a bladder contraction at a 150-ml volume and at 50-ml increments thereafter until maximum functional capacity was reached. Bladder compliance and bladder capacity were determined and the presence of detrusor instability (DI) was documented. Sixty-five patients (71%) presented after radical prostatectomy (RP) and 27 patients (29%) after transurethral resection of the prostate (TURP). The predominant urodynamic finding was sphincteric incompetence as VLPP were obtained in 85 patients (92%) and ranged from 12 to 120 cm water. DI was a common finding, occurring in 34 patients (37%), and classified as follows: a) phasic instability in 22/34, b) tonic instability in 3/34, and c) mixed phasic and tonic instability in 9/34. However, we found DI to be the sole cause of incontinence in only 3/92 patients (3.3%). There was no statistically significant difference in the incidence of sphincteric incompetence after RP or TURP; however, TURP patients had a higher incidence of DI, which was statistically significant (P=0.019). There was no correlation of incontinence severity and VLPP when comparing preoperative pad usage to VLPP < or =70 or > or =71 cm water. Although bladder dysfunction may be contributing problem in patients with postprostatectomy incontinence, it is rarely the only mechanism for this disorder. VLPP does not correlate with incontinence severity. Although sphincteric incompetence is the most common mechanism contributing to incontinence after prostatectomy, bladder dysfunction may coexist or be an isolated cause of postprostatectomy incontinence. Therefore, urodynamic studies are important to illustrate the exact cause(s) of incontinence in each individual patient after prostatectomy.

Urethral opening pressure: its clinical significance in prostatic obstruction

In the evaluation of prostatic obstruction by using the pressure-flow study (PFS), we defined intravesical pressure at initiation of voiding as urethral opening pressure. This simple parameter could reflect the degree of compressive prostatic obstruction to some extent. The aim of this study is to analyze if a correlation exsists between clinical signs and urethral opening pressure, and if they bear any prognostic value in postoperative outcome of the patients. We analyzed 46 patients with clinical benign prostatic hypertrophy who underwent urodynamic evaluations including PFS. They were divided into 2 groups according to their urethral opening pressure. The high opening pressure was defined as greater than 70 cm water, which was noted in 24 patients (group A). Twenty-two patients had lower opening pressure (group B). Comparison of the clinical findings in these patients were reviewed. Medium-filling cystometry and PFS were performed transurethrally, by using a microtip transducer and rectal balloon. Cystoscopy was performed when possible, wherein we could examined the presence or absence of detrusor trabeculation. Transurethral prostatectomy was indicated in a total of 26 patients (16 in group A and 10 in group B), in whom postoperative clinical findings were analyzed with regard to the difference in preoperative urethral opening pressure. The patients who void with straining or who void following uninhibited detrusor contraction were excluded from this study. International Prostatic Symptoms Score (I-PSS) revealed no significant difference in both groups, however, patients in group A were often suffering from urge incontinence preoperatively. Significant correlation was found among the incidence of detrusor instability, detrusor trabeculation and increased opening pressure. In PFS the patients with high opening pressure tended to have higher detrusor pressure at maximum flow and greater contractile power of the detrusor in voiding. There were no difference in Qmax and residual volume both groups. Postoperatively, symptomatic improvement was significant in both groups. There was no statistical difference in postoperative I-PSS between group A and B. Although 6 patients in group A demonstrated poor urinary control at 1 month, only two patients remained incontinent at 6 months postoperatively. As to urodynamic findings, the difference in PFS were markedly reduced between both groups. No difference was noted in postoperative Qmax as well. Significant difference was found in preoperative objective findings except the flow rate between the patients with and without high urethral opening pressure, while no symptomatic difference was noted except urege incontinence in both groups. No prognostic value was demonstrated in urethral opening pressure, however, poor postoperative urinary control was often associated with initial high opening pressure in the short term. It was suggested that 1) compensatory detrusor hyperactivity improved voiding efficacy in the patients with prostatic obstruction, which was gradually normalized after the relief of obstruction, 2) symptomatic improvement was highly related to the relative improvement of the obstructive findings on PFS.

Modified Pubovaginal Sling for Treatment of Intrinsic Sphincteric Deficiency

Purpose We report on 63 women undergoing modified pubovaginal fascial sling construction for treatment of intrinsic sphincteric deficiency. We specifically evaluated duration of postoperative urinary retention, persistence of urinary incontinence and incidence of detrusor instability. Materials and Methods Preoperative questionnaires, fluoro-urodynamic studies, hospital and clinical records, and postoperative questionnaires were reviewed to assess comparative outcome among the patients. Failed procedures were studied with fluoro-urodynamics. Patient followup ranged from 3 to 27 months (mean 11.7). Results Of the 63 patients 2 (3.2 percent) remained in long-term urinary retention, 4 (6.3 percent) had persistent stress incontinence and 3 (4.8 percent) had long-term detrusor instability. Two patients (3.2 percent) required reoperation for relief of persistent urinary retention (1) and for repair of anteriorly disrupted suspensory sutures (1). Review of preoperative fluoro-urodynamic studies did not provide insight into patients who would experience the aforementioned outcomes. Conclusions Our study confirmed the success of the modified pubovaginal fascial sling for treatment of intrinsic sphincteric deficiency. We were unable to obtain useful preoperative information from fluoro-urodynamic studies to predict which patients would experience failure to return to normal voiding.

Conventional, continuous, and telemetric monitoring of urodynamic parameters in non-human primates: A comparative study

A comparison between three different techniques for monitoring urodynamic parameters in non-human primates was conducted in six adult female rhesus monkeys. This study was divided into two phases. In phase I, the animals were studied by conventional and continuous methods. During the study, uroflow and micturition pattern were obtained while the animals housed in a specially designed metabolic cage. Pressure transducers and EMG electrodes were surgically implanted. Then the animals were trained for 6 weeks to sit in a specially designed chair. Upon completion of the training period, continuous monitoring of the urodynamic parameters could be carried out for periods up to 14 hours. In phase II, the animals were studied with the conventional and telemetric methods. The same type of pressure transducers and EMG electrodes were implanted but they terminated in a radio transmitter powered by a long-life battery and controlled by a radio-operated switch. Conventional studies under ketamine sedation significantly increased bladder capacity, as well as the pressure at capacity (P < 0.05). Continuous monitoring was feasible, physiological, and more sensitive than the conventional techniques. Telemetric studies are superior to continuous monitoring, since the animal is not tethered to wires and provide data over a longer period of time. It is concluded that telemetric monitoring provides significantly different parameters, which could help in diagnosis and management of different voiding dysfunctions. In normal non-human primates, lower bladder capacity, higher maximum voiding pressure, higher bladder compliance, and higher incidence of detrusor instability without urethral relaxation were found. Telemetric urodynamic data on different pathological processes are currently unavailable and further work is needed in this area.

In reply

Although transient urinary incontinence is not uncommon in the elderly, it was not relevant to our patient group. Checks for fecal impaction were done during the period baseline. The great majority of patients studied were long-term residents of their nursing homes and their urinary incontinence (UI) well documented prior to formal entry into the study. Criteria for entry as described under procedures included 0.5 or more incontinent episodes per day; thus, patients were wet at least every other day. Our finding of detrusor instability (DI) in 50/133 patients (38%) is at variance with previously reported prevalence from 54%–61%. Simple water cystometry without subtracted pressure should, however, overestimate rather than underestimate the presence of DI since observed increases in intravesical pressures include contributions from increases in intraabdominal pressures as well. The criteria for DI did include an increase in intravesical pressure of 15 cm of water or more. Our preliminary studies were instituted in 1983 when this met the ICS definition for detrusor instability. I agree this definition would have contributed to our underestimating the incidence of DI. The increases in intravesical pressure we observed in patients with bladder volumes >299 cc were slow incremental increases, which we considered to represent decreased bladder compliance rather than DI. Though not meeting previously established criteria, these patients were considered to have sufficient functional storage capacity to benefit from a bladder training program. I fully agree that defining voluntary or involuntary contractions in this cognitively impaired population, obtaining accurate post-void residual urine volumes, and defining stress incontinence in this largely immobile and functionally impaired population are very difficult tasks. This is, however, consistent with our conclusion that UI in this elderly population is likely not a simple matter of “pathourophysiology” but represents another significant aspect of global patient impairment and dependency in other areas of their daily activities. More sophisticated urodynamic testing does permit finer discrimination and increases diagnostic categories of bladder impairment, including mixed incontinence and detrusor hyperactivity with impaired contractility. However, it remains to be demonstrated by groups utilizing these more sophisticated testing techniques that the additional data and categorization can be used to develop effective treatment strategies involving simple surgical procedures, drugs, or behavioral therapy in this very fragile, multiply impaired, elderly patient population.

Prostatectomy or Conservative Management in the Treatment of Benign Prostatic Hypertrophy?

Summary— A randomised, prospective trial comparing transurethral prostatectomy with conservative management was carried out in 38 men with proven bladder outflow obstruction. Patients were assessed urodynamically before treatment and 6 months later. All 21 patients who had a prostatectomy showed a significant improvement in peak flow rate, voiding pressures and residual urine volume, but only 71 % were symptomatically better. Of the 17 patients treated conservatively, 56% noted an improvement in their symptoms, although their peak flow rates and residual urine volume were virtually unchanged. Following prostatectomy, the incidence of detrusor instability fell by 78%, whereas in the conservatively treated group the reduction was only 50%. Patients who had done well or badly after treatment were analysed as separate subgroups. The single feature which distinguished between these two groups was the high incidence of reversion to bladder stability in those who had a good symptomatic response to treatment.

Bladder function after radical hysterectomy

SummaryThirteen women were studied prospectively after radical hysterectomy alone. Despite preservation of the posterolateral centimetre of the cardinal ligament there were reductions in flow rate, functional urethral length and maximum urethral closure pressure. Adjuvant postoperative radiotherapy caused a high incidence of detrusor instability but less impaired voiding than radical hysterectomy alone.

Comparison of Long‐term Monitoring and Standard Cystometry in Chronic Retention of Urine

Twenty-eight men with chronic retention of urine were investigated by means of a standard medium fill cystometrogram and by long-term monitoring of bladder pressure whilst the bladder filled naturally. Effective cystometric capacity was greater in each patient during standard cystometry (297 +/- 180 ml) than during long-term monitoring (99 +/- 100 ml; P less than 0.002). The incidence of detrusor instability was also greater during long-term monitoring than during standard cystometry (P less than 0.01). During filling, the detrusor pressure increased significantly both in standard cystometry (27.9 +/- 22.8 cmH2O; P less than 0.002) and in long-term monitoring (4.9 +/- 6.5 cmH2O; P less than 0.002). The detrusor pressure rise during filling was significantly greater during the standard cystometrogram than during long-term monitoring (P less than 0.002). Even when the detrusor pressure rise was corrected to take account of the different cystometric capacities this difference persisted (P less than 0.05). High end filling pressures are common in men with chronic retention investigated by means of a standard cystometrogram but are not observed during long-term monitoring. Such high pressures are probably due to the unphysiological rates of filling and the large volumes of fluid instilled during standard cystometry.

Determinants of cure by endoscopic suspension of the bladder neck in the incontinent female patient

This paper reviews preoperative clinical observations that may predict the postoperative success of patients treated surgically for urinary incontinence. The impact of a surgical procedure on the bladder and urethra is evaluated using data obtained prospectively. All patients reviewed have been operated upon using endoscopic bladder neck suspension only. Parameters considered included the demonstration of urethral incontinence, history of urgency incontinence, prior urogenital surgery, and detrusor stability. The result of endoscopic suspension is evaluated in terms of cure rate or improvement one year after surgery. The postoperative outcome of bladder neck suspension is related to the preoperative considerations of detrusor stability, preoperative urgency and prior surgery. The results show that among the 161 patients complaining of incontinence only about half have demonstrable urethral incontinence. Of these, 23% have detrusor instability in addition to their urethral incontinence. The incidence of detrusor instability among the patients without demonstrable urethral incontinence was 48%. Patients with a stable detrusor preoperatively show the highest surgical cure rate (62% compared to 38% among patients with detrusor instability). Furthermore, patients without previous urogenital surgery that are stable report an even higher cure rate (90%). Presence of preoperative urgency compromises the possibility of complete surgical cure of incontinence. Urgency incontinence is present in approximately 48% of the patients whether stable or unstable. Endoscopic suspension will cure more than half of the patients with urgency incontinence if they have a stable detrusor function by urodynamic criteria preoperatively. However, patients with detrusor instability and urgency incontinence preoperatively are unlikely to report any improvement of their urgency incontinence following surgery. It is concluded that the determinants of successful bladder neck suspension are in order of priority: detrusor stability, preoperative urgency, and prior urogenital surgery.

Stress inconthence and detrusor instability/urge incontinence

AbstractThe overall incidence of detrusor instability in 603 women with stress incontinence was 30%. One hundred seventy‐two women had detrusor instability and/or urge incontinence preoperatively. Twenty‐three additional women developed detrusor instability and/or urge incontinence only after operation. By eight weeks after operation 4% of the entire group or 14% of those who had detrusor instability or urge incontinence at any time pre‐or postoperatively still had the difficulty with incontinence. These findings indicate that a small number of women with both stress incontinence and detrusor instabilty and/or urge incontinence will still have symptomatic urinary loss as a result of persistent detrusor abnormalities at eight weeks after operation.

Urodynamic assessment and chain cystogram in women with stress urinary incontinence Clinical significance of detrusor instability

A retrospective analysis of 51 women presenting with stress urinary incontinence was performed. Preoperative assessment protocol consisted of a careful history and physical examination, urinalysis and culture, cystoscopy, urodynamic study, beaded-chain cystogram, and intravenous pyelogram (IVP). All patients in the study were subjected to the Marshall-Marchetti-Krantz vesicourethral suspension procedure. The overall incidence of detrusor instability was 38.8 per cent. Surgical success rate was 92.5 per cent. Identification of detrusor instability was considered not to be a deterrent to surgery, nor a prognosticator of surgical failure. The chain cystogram was believed to be of little value in cases that had undergone previous surgical corrective attempts. Urodynamic studies were felt helpful in patients presenting with mixed symptom patterns, as well as in patients previously operated on for stress urinary incontinence. The preoperative IVP was not found to be a cost-effective study.

Urodynamic evaluation of transurethral versus transvesical prostatectomy. A randomized study.

In a randomized study of transurethral prostatectomy (TURP) versus transvesical prostatectomy (TVP) in 75 patients a urodynamic evaluation was undertaken before and 6 months following operation. In the TURP group a resection to the surgical capsule was attempted in each case. Operative specimen weights in the two groups did not differ statistically significantly. 5 patients in each group had unexpected prostatic carcinoma. Rapid fill CO2 cystometry did not show any significant differences in bladder function between TURP and TVP patients 6 months following operation. In both groups a high incidence of detrusor instability was observed at follow-up. However, the incidence as well as the severity of the instability had decreased significantly following the two operative procedures. As judged from flowmetry and pressure flow investigation, relief of infravesical obstruction was almost complete in both groups. However, following treatment of postoperative strictures the patients with benign histology in the TVP group compared to the TURP group had higher maximum flow rate values and lower detrusor pressure values. Confidence limits for the differences between the two groups in detrusor pressure and maximum flow rate at follow-up did, however, hardly suggest clinically significantly differences. At urethral closure pressure profile measurement a statistically significantly shorter profile length was measured in TVP patients. The marginal differences in relief or infravesical obstruction might be due to differences in the amount of apical prostatic adenoma following operation.