Lower Detrusor Pressure Research Articles

Identifying occult bladder outlet obstruction in women with detrusor-underactivity-like urodynamic profiles

Voiding dysfunction can result from detrusor underactivity (DU), bladder outlet obstruction (BOO), or both. Conceptually, women with high-pressure low-flow urodynamic profiles are diagnosed with BOO without DU. However, the possibility of BOO is often neglected in women with DU-like (low-pressure low-flow) urodynamic (UDS) profiles. By reviewing the videourodynamic studies (VUDS) of 1678 women, our study identified the key factors suggesting urodynamic BOO (determined by radiographic evidence of obstruction) in women with DU-like UDS profiles (Pdet.Qmax < 20 cmH2O and Qmax < 15 mL/s). In 355 women with DU-like UDS profiles, there were 70 (19.7%) with BOO and 285 (80.3%) without BOO. The BOO group had predominantly obstructive symptoms. The BOO group showed significantly decreased bladder sensation, lower detrusor pressure (Pdet.Qmax), lower flow rate (Qmax), smaller voided volume, and larger post-voiding residual (PVR) compared to the non-BOO group. In multivariate analysis, volume at first sensation, Qmax, PVR, and detrusor overactivity (DO) remained independent factors for BOO. The receiver operating characteristic (ROC) areas for the parameters were largest for PVR (area = 0.786) and Qmax (area = 0.742). The best cut-off points were 220 mL for PVR and 4 mL/s for Qmax. Our findings provide simple indicators for BOO in women with DU.

Underactive Bladder Syndrome: An Often Overlooked Condition

Urinary bladder outlet obstruction can cause lower urinary tract symptoms in men and women, such as a weak or interrupted urine stream, straining to void, hesitancy, and the feeling of incomplete bladder emptying. These symptoms can also be associated with underactive bladder syndrome. This urological condition has a high prevalence in both genders, especially in older age groups. The most common risk factors that can contribute to the pathogenesis of underactive bladder syndrome are aging, detrusor myopathy, neuroinflammatory, neurodegenerative and other lesions of the central and peripheral nervous system, and diabetes mellitus. Reduced detrusor contractility, or detrusor underactivity, is the most common pathology of underactive bladder syndrome. Detrusor underactivity is a urodynamic definition provided by the International Continence Society. The urodynamic trace is characterised by a low urine flow rate accompanied by low detrusor pressure or brief detrusor muscle contraction. Underactive bladder syndrome is often recognised and treated poorly in clinical practice because the symptoms are not specific. Furthermore, underactive bladder can be asymptomatic or coexist with bladder outlet obstruction and overactive bladder syndrome. The aim of this study was to review recent research concerning the aetiology, classification, diagnostic evaluation, and available treatment methods for patients with symptoms of underactive bladder syndrome. Making an accurate underactive bladder diagnosis is challenging because it is a multifactorial condition with various patterns of manifestation. Consequently, there is still no general agreement and standardisation regarding the most favourable diagnostic and therapeutical approach.

Early sacral neuromodulation ameliorates urinary bladder function and structure in complete spinal cord injury minipigs.

AimsTo determine the effects of early sacral neuromodulation (SNM) and pudendal neuromodulation (PNM) on lower urinary tract (LUT) function, minipigs with complete spinal cord injury (cSCI) were analyzed. SNM and PNM have been proposed as therapeutic approaches to improve bladder function, for example after cSCI. However, further evidence on efficacy is required before these methods can become clinical practice.MethodsEleven adults, female Göttingen minipigs with cSCI at vertebral level T11‐T12 were included: SNM (n = 4), PNM (n = 4), and SCI control (SCIC: n = 3). Tissue from six healthy minipigs was used for structural comparisons. Stimulation was started 1 week after cSCI. Awake urodynamics was performed on a weekly basis. After 16 weeks follow‐up, samples from the urinary bladder were taken for analyses.ResultsSNM improved bladder function with better capacities and lower detrusor pressures at voiding and avoided the emergence of detrusor sphincter dyssynergia (DSD). PNM and untreated SCI minipigs had less favorable outcomes with either DSD or constant urinary retention. Structural results revealed SCI‐typical fibrotic alterations in all cSCI minipigs. However, SNM showed a better‐balanced distribution of smooth muscle to connective tissue with a trend towards the reduced progression of bladder wall scarring.ConclusionEarly SNM led to an avoidance of the emergence of DSD showing a more physiological bladder function during a 4 month follow‐up period after cSCI. This study might pave the way for the clinical continuation of early SNM for the treatment of neurogenic LUT dysfunction after SCI.

Recovery of Voiding Efficiency and Bladder Function in Male Patients With Non-neurogenic Detrusor Underactivity After Transurethral Bladder Outlet Surgery

ObjectiveThe aim of this study is to investigate the treatment outcome in men with detrusor underactivity (DU) and voiding dysfunction who underwent transurethral resection or incision of the prostate (TURP or TUIP). DU usually affects decision making whether bladder outlet surgery is necessary. Materials and MethodsA total of 60 men with urodynamic DU and voiding dysfunction who underwent TURP or TUIP from 1998 to 2015 were retrospectively analyzed for their treatment outcome after follow-up for more than 1 year. DU was defined as urodynamic evidence of low detrusor pressure (<40 cm H2O), low flow rate (<10 mL/s), a postvoid residual urine volume >300 mL, and a voiding efficiency (VE) of <33%. Satisfactory outcome was defined as improved quality of life and having a VE of >50% after treatment. Predictive factor for a successful outcome was also analyzed. ResultsAt a mean follow-up of 31 months, 49 (81.7%) patients had achieved a satisfactory treatment outcome. Among the patients who received TURP and TUIP, 38/44 (86.4%) and 11/16 (68.8%) had satisfactory outcome, respectively. The satisfactory group had significantly higher detrusor pressure and greater bladder compliance at baseline than the unsatisfactory group. There was significant improvement in the urodynamic parameters after treatment in the satisfactory group. Among the patients with satisfactory outcome, 34 (69.4%) patients had recovery of detrusor function within 3 months. ConclusionActive surgical treatment such as TURP or TUIP results in recovery of VE and detrusor function within 3 months after treatment in the majority of patients with DU.

A Modern Comparison of Urodynamic Findings in Diabetic Versus Nondiabetic Women.

Few contemporary studies exist regarding urodynamic (UDS) findings in patients with diabetes mellitus (DM), and data are conflicting. Our aim was to compare UDS findings in women with and without DM. Data from female patients in a prospectively maintained UDS database (2010-2014) were reviewed. Studies were performed according to International Continence Society standards. Clinical data, presenting symptoms, and UDS findings were compared in women with and without DM, controlling for demographic and pertinent variables. There were 384 patients who met the inclusion criteria, of whom 88 (26%) had DM. Symptoms at presentation were not statistically different in women with and without DM. Women with DM had larger bladder capacity (mean, 493 mL vs 409 mL; P = 0.005) and had more detrusor underactivity (30% vs 18%, P = 0.042) when compared with nondiabetic women. Diabetic women were more frequently diagnosed as having impaired sensation, or lack of desire to void, at 75% of capacity (17% vs 5%, P = 0.001). In women with diabetes, a serum hemoglobin A1c level of at least 7.5% was associated with delayed first sensation and first urge. Diagnosis of DM of more than 10 years was associated with greater volume at first urge, and maximal capacity, lower detrusor pressures, and higher postvoid residual. In this contemporary series, women with DM demonstrated similar presenting complaints to women without DM but had significantly altered UDS findings. Among diabetic female patients, diabetes control and duration of diabetes seem to impact bladder sensation and contractility. Urodynamics may be helpful in diabetic female patients to diagnose underlying concealed bladder dysfunction before initiation of treatment.

MP27-17 COULD DETRUSOR OVERACTIVITY PREDICT THE USE OF ANTIMUSCARINICS AFTER MID-URETHRAL SLING IN WOMEN WITH MIXED URINARY INCONTINENCE?

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Incontinence: Evaluation (Urodynamic Testing)1 Apr 2018MP27-17 COULD DETRUSOR OVERACTIVITY PREDICT THE USE OF ANTIMUSCARINICS AFTER MID-URETHRAL SLING IN WOMEN WITH MIXED URINARY INCONTINENCE? Yun-Chu Chang, Yu-Hua Fan, and Alex T.L. Lin Yun-Chu ChangYun-Chu Chang More articles by this author , Yu-Hua FanYu-Hua Fan More articles by this author , and Alex T.L. LinAlex T.L. Lin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.896AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Patients with mixed urinary incontinence (MUI) suffer from components of both stress urinary incontinence (SUI) and overactive bladder (OAB). Many studies have shown that surgical management of SUI with a mid-urethral sling (MUS) may help OAB symptoms. It is important to evaluate the predictive factors of change in OAB symptoms after MUS in MUI patients. We conduct this study to evaluate whether detrusor overactivity (DO) could predict the change in OAB symptoms after MUS in women with MUI. METHODS We retrospectively recruited female patients with MUI treated with retropubic synthetic MUS between 2008 and 2015. All patients completed the questionnaires of Overactive Bladder Symptoms Score (OABSS) and Urogenital Distress Inventory (UDI-6) preoperatively. MUI was defined as clinical SUI with positive response to urgency or urge incontinence subscale of OABSS, or urge incontinence subscale of UDI-6. All patients underwent videourodynamic study prior to MUS. The primary outcome was the postoperative use of antimuscarinics defined as the prescription of antimuscarinics one month after MUS for more than one month. We evaluated the effects of DO and other potential risk factors for the primary outcome. RESULTS A total of 187 patients were included in the study, with 35 demonstrated with DO and 152 without DO. 26 patients with DO and 110 patients without DO required postoperative antimuscarinics. The mean duration of postoperative antimuscarinics was 6.2 ± 4.1 months. There was no significant difference in postoperative antimiscarinics between patients with and without DO. However, patients with lower detrusor pressure at maximum flow tended to use antimuscarinics after MUS in DO patients. Age, body mass index and the combination of pelvic organ prolapse surgery were similar between patients with and without postoperative antimuscarinics. Urgency and urge incontinence subscores of OABSS were significantly higher in patients with postoperative antimuscarinics than those without. Besides, urgency subscore of UDI-6 was significantly higher in patients requiring postoperative antimuscarinics. CONCLUSIONS DO alone could not predict the use of antimuscarinics after MUS in women with MUI. Nevertheless, DO patients with lower detrusor pressure at maximum flow have the tendency toward using postoperative antimuscarinics. MUI women with more severe baseline urgency and urge incontinence have higher possibility to use antimuscarinics after MUS. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e354 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Yun-Chu Chang More articles by this author Yu-Hua Fan More articles by this author Alex T.L. Lin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD48-07 BLADDER CHANGES AFTER CATHETERIZABLE CHANNEL CREATION IN ADULTS WITH CEREBRAL PALSY WHO ARE IN CHRONIC URINARY RETENTION PRE-OPERATIVELY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Transitional Urology & GU Congenitalism1 Apr 2018PD48-07 BLADDER CHANGES AFTER CATHETERIZABLE CHANNEL CREATION IN ADULTS WITH CEREBRAL PALSY WHO ARE IN CHRONIC URINARY RETENTION PRE-OPERATIVELY Vikram Narayan, Ronak Gor, Jenna Katorski, and Sean Elliott Vikram NarayanVikram Narayan More articles by this author , Ronak GorRonak Gor More articles by this author , Jenna KatorskiJenna Katorski More articles by this author , and Sean ElliottSean Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2311AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Cerebral palsy (CP) is characterized by motor impairments as a result of injury to the brain during development. These patients are often unable to self-catheterize through their native urethra due to fine motor impairments and muscle spasticity of the limbs & pelvic floor. Chronic retention can be alleviated with catheterizable channel (CC) creation. But, we have observed that some patients with large capacity, low-pressure bladders who are in chronic urinary retention due to pseudodyssynergia pre-operatively, develop de novo neurogenic detrusor overactivity (NDO) post-operatively. We sought to better characterize this finding. METHODS We retrospectively reviewed the charts of 8 patients 17 years of age or older with a diagnosis of CP who underwent surgical creation of CC without an augmentation cystoplasty in 2011-2017. We have limited augmentation cystoplasty to those CP patients (n=11) with poor bladder compliance, refractory NDO or small bladder capacity; these are not the focus of this study. Pre-operative and post-operative UDS were reviewed, where available. Clinical data, including frequency of incontinence, use of anti-cholinergics, and need for intravesical injections of onabotulinum toxin A before and after surgery were reviewed. Descriptive summaries were tabulated. RESULTS All 8 patients had low detrusor pressures and bladder volumes of at least 250 mL (mean 528 mL) on UDS before surgery. Seven of these patients had severe CP based on the Gross Motor Function Classification System (GMFCS), with a grade of either IV or V, and one was grade III. Pre-operatively, 6 of 8 patients were in chronic retention. These patients all reported worsening incontinence post-operatively. Before surgery, 5 of 8 patients were managed with either anticholinergics or intravesical onabotulinum toxin A. Following CC creation, all patients who were previously in chronic retention required NDO management with either additional anticholinergics, intravesical onabotulinum, or mirabegron. Among those with complete UDS data (6/8 patients), 67% demonstrated lower maximum cystometric capacity post-operatively, with an average volume loss of 88.5 ±81.2 mL (SD). Median follow-up was 25 months. CONCLUSIONS Catheterizable channel creation facilitates CIC in adults with severe CP who are in chronic retention due to psuedodyssynergia. However, despite pre-operative UDS that demonstrate a large capacity, low pressure bladder, such patients often manifest diminished bladder capacities and new NDO upon initiation of CIC after surgery. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e963 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Vikram Narayan More articles by this author Ronak Gor More articles by this author Jenna Katorski More articles by this author Sean Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Videourodynamic characteristics of interstitial cystitis/bladder pain syndrome-The role of bladder outlet dysfunction in the pathophysiology.

To investigate the characteristics of videourodynamic study (VUDS) in females with interstitial cystitis/bladder pain syndrome (IC/BPS) focusing on the etiologies of bladder outlet dysfunction (BOD) and their associations with clinical and urodynamic parameters. IC/BPS females with complete data on symptom assessment, VUDS, the potassium sensitivity test, and cystoscopic hydrodistention were reviewed retrospectively. Diagnoses of bladder dysfunction (hypersensitive bladder, HSB) and BOD including dysfunctional voiding (DV), poor relaxation of the external urethral sphincter (PRES), and bladder neck dysfunction (BND) were made by VUDS. The clinical and urodynamic parameters between patients with normal and abnormal VUDS diagnoses were analyzed. A total of 348 IC/BPS female patients (mean age 48.8 ± 13.5) were enrolled. HSB was found in 307 (88.2%) patients and BOD in 209 (60.1%). The causes of BOD included DV in 40 (11.5%), PRES in 168 (48.3%), and BND in 1 (0.3%). Patients with DV and BND had higher, and those with PRES had lower detrusor pressures at maximum flow rate (Qmax ) than those with normal tracings. For all BOD patients, univariate logistic regression revealed a significant positive correlation of disease duration and negative correlations of urodynamic volume parameters with BOD in IC/BPS patients. Multivariate logistic regression found a cut-off value of Qmax ≦ 11 mL/s predicted BOD in IC/BPS with a receiver operating characteristic area of 0.81 (sensitivity = 82.0%, specificity = 68.5%). HSB and BOD are common findings on VUDS in IC/BPS females. BOD is associated with duration and hypersensitive bladder. A Qmax ≦ 11 mL/s predicts BOD in IC/BPS.

Risk factors for stress urinary incontinence after native-tissue vaginal repair of pelvic organ prolapse.

To identify risk factors for postoperative stress urinary incontinence (POSUI) after native-tissue prolapse repair without a concomitant anti-incontinence procedure. The present single-center retrospective study included women with genital prolapse who underwent high uterosacral ligament suspension without a concomitant anti-incontinence procedure during 2008-2013. Univariate and multivariate analyses were performed to identify risk factors for POSUI (identified through clinical interview and International Consultation on Incontinence Modular Questionnaire-Short Form [ICIQ-SF] self-administration) at 6months. In total, 87 (20.9%) of 417 women developed POSUI. Preoperative stress urinary incontinence (SUI) and urodynamically diagnosed SUI were significantly associated with POSUI; moreover, women with POSUI had a higher preoperative ICIQ-SF score, a lower opening detrusor pressure, and a lower detrusor pressure at maximum flow than did women without POSUI (P<0.05 for all comparisons). In the multivariate analysis, preoperative SUI (odds ratio 3.11), a detrusor pressure at maximum flow of less than 30cm H2 O (odds ratio 2.93), and urodynamically diagnosed SUI (odds ratio 2.26) were independent risk factors for POSUI. Preoperative urodynamic parameters, obtained before prolapse repair surgery, were associated with POSUI and could be useful in providing adequate counseling to facilitate decision making on whether to add a concomitant anti-incontinence procedure.

Risk factors for stress urinary incontinence recurrence after single-incision sling.

The aim of the study was to identify in a pure stress urinary incontinence (SUI) population risk factors for recurrence after single-incision slings (SIS). This retrospective study analyzed women with complaints of SUI symptoms and urodynamically proven SUI. Exclusion criteria were recurrent SUI, overactive bladder syndrome/detrusor overactivity, preoperative postvoid residual >100 mL, reduced urethral mobility (<10° at the Q-tip test), concomitant anterior prolapse >I stage and previous history of radical pelvic surgery. Objective cure rate was assessed with stress test. A total of 192 patients were analyzed. Objective cure rate was obtained in 86.5% of patients. According to univariate analysis, recurrences had higher prevalence of severe ICIQ-SF score (≥18 points), higher prevalence of reduced urethral mobility (Qtip ≤30°), higher prevalence of low detrusor pressures during voiding phase (opening pressure <15 cmH2 O, pressure at maximum flow <20 cmH2 O, closing pressure <15 cmH2 O), and higher prevalence of postoperative complications According to multivariate analysis ICIQ-SF score ≥18 points (P = 0.02; OR = 2.7) and detrusor pressure at maximum flow <20 cmH2 O (P < 0.01; OR = 3.6) resulted as independent risk factors for SUI recurrence (Table 3). A trend was found for urethral mobility ≤30° (P = 0.07; OR = 2.2). Our study identifies SUI severity expressed with ICIQ-SF scores and low detrusor pressure at maximum flow as independent risk factors for SUI recurrence after SIS implantation while only a trend was found for reduced urethral mobility. Therefore, preoperative assessment of symptoms and urodynamics evaluation may play a key role in improving preoperative counseling and tailoring surgical treatment.

Risk factors analysis of persistent frequency after transurethral resection of the prostate

Objective To discuss the risk of factors influencing persistent frequency after transurethral resection of the prostate (TURP). Methods The clinical data of 119 post-TURP patients treated from January 2014 to June 2015 was retrospectively analyzed. The age was (72.1±2.3)years old. There were 15 cases with hypertension, 23 cases with diabetes and 6 cases with heart disease. The preoperative IPSS score of 119 cases was (22.1±5.9) points, with (10.2±1.8) points in urinary storage period and (11.8±4.7) points in urination period. Urination frequency was (10.8±2.6) times per day and there were (3.8±0.8) times of nocturnal urination. B-ultrasound: residual urine volume was (38.1±9.1) ml and prostate volume was (34.1±4.2) ml. Preoperative maximum urine flow rate was (8.8±3.9) ml/s. The detrusor pressure at maximum urinary flow rate was (43.9±14.1) cm H2O (1 cmH2O = 0.098 kPa), maximum detrusor pressure was (99.7±12.2) cmH2O and effective bladder volume was (217.5±14.8) ml. Contraction of bladder weakened in 40 cases (33.6%) and 36 cases (30.2%) had detrusor overactivity. According to whether continuous urinary frequency was developed, the patients were divided into frequency-positive group and frequency-negative group. The differences between the patients in two groups were compared and univariate analysis was performed. A multivariate logistic regression was performed on statistically significant indicators. Results Among the 119 patients, 21 were frequency-positive and 98 were frequency-negative. Univariate analysis showed that age, IPSS score, preoperative urinary storage score, detrusor pressure at maximum urinary flow rate, maximum detrusor pressure, effective bladder volume, contraction decrease of bladder, preoperative detrusor activity were important indicators affecting the condition of postoperative urinary frequency (all P<0.05). Multivariate analysis showed that old age (OR=3.842, P=0.021), high total IPSS score (OR=5.109, P=0.011), low maximum detrusor pressure (OR=3.477, P=0.039), low effective volume of bladder (OR=4.051, P=0.017) and detrusor overactivity (OR=3.662, P=0.025) were independent risk factors for urinary frequency after TURP. Conclusions The age, the high IPSS score before operation, low maximal detrusor pressure, low effective bladder capacity and the bladder detrusor activity could be independent predictive factors of persistent frequency after TURP. Key words: Transurethral resection of prostate; Persistent frequency; Risk factors

The effect of onabotulinumtoxinA according to site of injection in patients with overactive bladder: a systematic review and meta-analysis.

This study assessed the efficacy and safety of onabotulinumtoxinA according to injection site for treatment of overactive bladder. A systematic literature review located randomized controlled trials of onabotulinumtoxinA treatment for neurogenic detrusor overactive bladder and idiopathic overactive bladder in adults. We searched MEDLINE, EMBASE, and the Cochrane Controlled Trials Register using the Ovid platform. Meta-analysis was based on Cochrane Review Methods. Eight studies (419 participants) were included. Trigone-including injection demonstrated a significant improvement in symptom score (SMD=-0.53, 95% CI -1.04 to -0.02, P=0.04, I 2=78%), higher complete dryness rates (OR=2.19 patients, 95% CI 1.32-3.63, P=0.002, I 2=41%), and lower frequency of incontinence episodes (WMD=-0.85 per day, 95% CI -1.55 to -0.16, P=0.02, I 2=87%) in patients. Comparing trigone-including injection to trigone-sparing injection, lower detrusor pressure (WMD=-2.55cm H2O, 95% CI -4.16 to -0.95, P=0.002, I 2=0%) and higher volume at first desire to void (WMD=17.54ml, 95% CI 1.00-34.07, P=0.04, I 2=0%) were observed with trigone-including injection. Between intradetrusor and suburothelial injection sites, there were no differences in efficacy or safety regarding the incidence of vesicoureteral reflux, hematuria, general weakness, bladder discomfort, large post-void residual, and urinary tract infection. Trigone-including onabotulinumtoxinA injection has superior efficacy to trigone-sparing injection without increased complications. The depth of injection does not influence the efficacy or safety of onabotulinumtoxinA.

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.

Functional outcome of supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction.

To investigate the functional outcome after supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction (NLUTD). Retrospective follow-up investigation in a single spinal cord injury rehabilitation center. In 29 patients, urodynamic data before and after supratrigonal cystectomy and augmentation ileocystoplasty, clinical outcome and post-operative complications were evaluated. The median age of the 29 patients at the time of surgery was 31 years, a median 14 years after NLUTD had occurred. At the last follow-up visit (median 2.4, range 0.4-9.0 years post-operatively), 20/29 patients (69%) were continent compared to 2/29 pre-operatively (P = 0.001). Furthermore, 16 patients required no or less detrusor relaxation therapy after augmentation ileocystoplasty. Augmentation cystoplasty resulted in a significant (P = 0.001) increase in the median bladder capacity (from 240 ml to 500 ml) and compliance (from 13 ml/cm H2 O to 50 ml/cm H2 O). The median maximum detrusor pressure had decreased significantly (P = 0.001) from 38 cm H2 O to 15 cm H2 O. Significantly (P = 0.001) fewer patients presented with a risk for renal damage (1 vs. 15 with maximum detrusor pressure >40 cm H2 O and 1 vs. 12 with detrusor compliance <20 ml/cm H2 O) at the last follow-up. The following complications were observed in 11/29 (38%) patients: paralytic and obstructive ileus, impaired bowel function, bladder stones, dehiscence, metabolic acidosis and autonomic dysreflexia. Protection of renal function, adequate bladder capacity and low detrusor pressure can be achieved using supratrigonal cystectomy and augmentation ileocystoplasty in patients suffering from refractory NLUTD.

MP76-19 A MODERN COMPARISON OF URODYNAMIC FINDINGS IN NONDIABETIC VERSUS DIABETIC FEMALES

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Non-neurogenic Voiding Dysfunction1 Apr 2014MP76-19 A MODERN COMPARISON OF URODYNAMIC FINDINGS IN NONDIABETIC VERSUS DIABETIC FEMALES Rena D. Malik, Joshua A. Cohn, Charles Chang, Leah Anderson, Brianne Randall, Gregory T. Bales, and Doreen E. Chung Rena D. MalikRena D. Malik More articles by this author , Joshua A. CohnJoshua A. Cohn More articles by this author , Charles ChangCharles Chang More articles by this author , Leah AndersonLeah Anderson More articles by this author , Brianne RandallBrianne Randall More articles by this author , Gregory T. BalesGregory T. Bales More articles by this author , and Doreen E. ChungDoreen E. Chung More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2412AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Classic diabetic cystopathy has been described as decreased sensation, increased capacity, impaired contractility, and elevated post void residual (PVR). Data is conflicting and few contemporary studies exist regarding urodynamics (UDS) findings in patients with diabetes mellitus (DM). To date no comparative studies exist. Our aim was to compare UDS findings in females with and without DM from a contemporary database. METHODS A retrospectively collected UDS database was searched for females and reviewed. Studies were performed according to International Continence Society Standards. For significance, chi square and Students t tests were performed. RESULTS 344 patients underwent UDS between 2010 and 2013. Of those 93 (27%) had DM. Indications for UDS and symptoms at presentation were similar in both groups, except diabetics more frequently presented with voiding symptoms (15% vs. 8%, p=0.05) and less frequently with nocturia (10% vs. 20%, p=0.03). UDS findings are summarized in table 1. Females with DM had significant delay to first urge sensation (278mL vs. 220mL, p =0.01), larger bladder capacity (mean 479 mL vs. 402mL, p = 0.01), and decreased maximum detrusor pressures (43 cmH2O vs. 57 cmH2O, p= 0.001). A larger proportion of females with DM had detrusor underactivity (29% vs. 17%, p=0.04), abdominal straining during voiding (55% vs. 41%, p=0.03) and a trend towards increase in post void residual (PVR) (53cc vs. 24cc, p=0.09). There was no difference in presence of detrusor overactivity, or stress incontinence between groups. CONCLUSIONS In this contemporary series, women with DM, demonstrated similar presenting complaints to women without DM but had delayed sensation, higher capacity, lower detrusor pressures and increased PVR consistent with classic diabetic cystopathy. These findings suggest that DM does affect bladder function but not symptoms and reinforces the importance of UDS in the workup of DM females, particularly prior to initiation of treatment. Further studies are needed to explore treatment implications of this phenomenon. Table 1. Urodynamic Findings in Females NonDiabetics (n= 251) Diabetics (n= 93) p Value Mean First Sensation ±SD (mL) 136 ± 128 169 ± 167 0.17 Mean First Urge ± SD (mL) 220 ± 158 278 ± 227 0.01 Mean Capacity ± SD (mL) 402 ± 227 479 ± 302 0.01 Mean Qmax ± SD (mL/s) 16 ± 12 19 ± 15 0.10 Mean Pdet at Qmax ±SD (cmH2O) 37 ± 26 27 ± 18 0.002 Mean Max Pdet ±SD (cmH2O) 57 ± 36 43 ± 30 0.001 Detrusor Overactivity (%) 72 (30) 26 (29) 1.0 Stress Incontinence (%) 121 (51) 48 (57) 0.45 Bladder Strength (%) Weak 37 (17) 20 (29) 0.04 Strong 181 (83) 48 (71) Mean PVR ±SD (mL) 34 ± 85 53 ± 109 0.09 Abdominal Straining (%) 96 (41) 47 (55) 0.03 © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e889-e890 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Rena D. Malik More articles by this author Joshua A. Cohn More articles by this author Charles Chang More articles by this author Leah Anderson More articles by this author Brianne Randall More articles by this author Gregory T. Bales More articles by this author Doreen E. Chung More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1192 MINITAPE READJUSTABLE TRANSOBTURATOR SLING: NOVEL, SIMPLE, NON-INVASIVE, POST OPERATIVE READJUSTMENT WITHIN 1 WEEK FOR RECURRENT STRESS INCONTINENCE FROM ANY PRIOR PROCEDURE, AND FOR HIGH RISK URINARY RETENTION PATIENTS

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence - Evaluation & Therapy II1 Apr 20121192 MINITAPE READJUSTABLE TRANSOBTURATOR SLING: NOVEL, SIMPLE, NON-INVASIVE, POST OPERATIVE READJUSTMENT WITHIN 1 WEEK FOR RECURRENT STRESS INCONTINENCE FROM ANY PRIOR PROCEDURE, AND FOR HIGH RISK URINARY RETENTION PATIENTS Matthew Karlovsky Matthew KarlovskyMatthew Karlovsky Phoenix, AZ More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1437AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Despite the success of midurethral slings (MUS) for stress urinary incontinence (SUI), a growing number of patients will fail the procedure, yet there is lacking adequate reporting and consensus on the best salvage option. Patients who have failed multiple incontinence procedures or with low detrusor pressures (Pdet) are high risk for poor outcomes for SUI surgery. High BMI and low leak point pressures (LPP) are other risk factors for MUS failure. The aim of the study is to see if a novel transobturator sling, that can be adjusted non-invasively, for up to 72hrs post operatively by loosening or tightening, can be used as a “catch-all” salvage sling regardless of prior SUI surgery or risk factor for sling failure. METHODS An 18 month prospective study was conducted on twenty four consecutive cases involving the Minitape RTS for recurrent SUI regardless of prior incontinence surgery, and on patients with high BMI and low Pdet, defined as </=10cm H2O. Placed “out-to-in” method, a suture, attached to each end of the 8cm sling is brought out the obturator skin, tied to a button which is either tightened or loosened if needed, but ultimately cut off within a week of surgery. All patients were informed of and consented to the unstudied nature of the sling. Baseline demographics on age, parity, BMI, prior failed surgery, hysterectomy status, LPP, MUI, sling tightening or loosening required, leak point pressure (LPP), Pdet, were collected. A follow up telephone call was made to see if the patient was “dry” and “satisfied”. RESULTS The mean and range of the patients’ age, parity, BMI, LPP, and Pdet were 64.3 (42-82), 2.45 (0-4), 30.9 (18.1-43.1), 93.5 (18-219), 10.1 (0-25), respectively. Median follow up was ten months. Eleven had one prior SUI surgery, five had 2 priors, and one had 3. Fifteen had Pdet </=10cm H20.They included fascial slings, MUS, injections, Burch/MMK, minislings, bone anchored slings and Kelly repairs. 21/24 (87.5%) were dry and satisfied, 1 (4.2%) was improved, and 2 (8.3%) failed. Eight required loosening, two required tightening, and 14 required no adjustment prior to button removal. Three had transient elevated residuals of >100cc at 1 week, which all resolved. CONCLUSIONS Regardless of prior SUI surgery type, BMI or Pdet, the Minitape RTS is a novel and promising tool for refractory SUI with low LPP, and/or low Pdet. It is the only readjustable sling that can be tightened or loosened as needed after surgery with only a scissor. Further study is warranted. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e482-e483 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Karlovsky Phoenix, AZ More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

2167 MAXIMUM ISOMETRIC DETRUSOR CONTRACTION IN MEN WITH POST-PROSTATECTOMY INCONTINENCE

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Urodynamic Testing1 Apr 20112167 MAXIMUM ISOMETRIC DETRUSOR CONTRACTION IN MEN WITH POST-PROSTATECTOMY INCONTINENCE Christopher Elliott and Craig Comiter Christopher ElliottChristopher Elliott Stanford, CA More articles by this author and Craig ComiterCraig Comiter Stanford, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2404AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Detrusor dysfunction in the form of poor contractility has been reported in up to 40% of men following radical prostatectomy, regardless of continence status. However, “true” detrusor contraction strengths have not been measured in these studies. Rather surrogates such as the presence of Valsalva voiding, low detrusor pressures at maximum flow (PdetQmax) or the use of bladder contractility nomograms developed for men with intact prostates have been used. To date the use of isovolumetric contraction pressure (Piso) to measure bladder contractility has not been reported in this population. We present our experience in men with post-prostatectomy incontinence (PPI). METHODS We performed a retrospective review of all men referred to our institution in the last 3 years for PPI evaluation. All men undergoing urodynamic examination during this time (62 of 65) were included for study. Videourodynamic evaluation was performed with a standard seven French urodynamic catheter using concomitant rectal pressure monitoring. A maximum isometric detrusor contraction measurement was obtained using the continuous occlusion test (COT). Statistical analysis was performed using Mann-Whitney and linear regression tests to evaluate the effect of patient variables on Piso. RESULTS Piso was measurable in 60 men with a median value of 60cmH2O (range 0–110). Piso was < 50 cm water in 24/60 (40%). Isometric contractility was higher in men with urodynamic evidence of detrusor overactivity (71.5 vs 47 cm water, p=.010) and in non-Valsalva voiders compared to Valsalva voiders (60 vs 24 cm water, p=.016). Piso was also positively correlated with PdetQmax (p<.001) and detrusor reserve (p<.001); it was negatively correlated with bladder compliance (p=.010). Isometric contraction strength was unrelated to age, time since radical prostatectomy, leak point pressure, pad use, history of pelvic radiation, maximum urinary flow rate or bladder capacity (p>.05 for all). CONCLUSIONS Our data suggest that detrusor contraction strength can be easily measured by the COT in men with PPI. Indeed, 40% of men demonstrated a Piso < 50 cm water. As low contractility is a relative contraindication to sling surgery, bladder contractility should be measured in men prior to incontinence surgery. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e867-e868 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Elliott Stanford, CA More articles by this author Craig Comiter Stanford, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Voiding dynamics in women with stress urinary incontinence and high‐stage cystocele

The aim of this study was to identify the urodynamic features of women with stress urinary incontinence (SUI) or with high-stage (stage 3 or greater) cystocele (HSC) as compared with symptom-free women. Fifty-six neurologically intact women with SUI and 47 women with HSC but without SUI were prospectively evaluated. All patients underwent full urodynamics, in addition to basic clinical evaluations. The urodynamic parameters of SUI and HSC were compared to the ones obtained from 78 urologically symptom-free normal women over the same period. Patients with HSC, after correction of cystocele using a temporary vaginal pessary, had consistently lower maximum urinary flow rate with a lower detrusor pressure during micturition than the controls or those with SUI. On the other hand, patients with SUI had an equivalent to higher maximum urinary flow rate, normal detrusor contraction strength with a lower detrusor pressure during micturition than the controls. Both maximum Watts factor and bladder contractility index were significantly lower in the whole HSC cohort in comparison to the controls and patients with SUI. The urodynamic characteristics observed among the three groups were all maintained even after adjusting for age. Women with SUI demonstrate voiding with low-pressure, normal contraction strength with an equivalent to high urinary flow rate. Women with HSC demonstrate voiding with low pressures with weak contraction strengths and low urinary flow rates, suggesting a higher prevalence of detrusor underactivity. Chronically decreased or increased urethral resistance might alter voiding dynamics and performance.

Editorial Comment

This is a novel experiment comparing the urinary flow rate parameters in varying positions in both boys and girls to determine the optimal position for urinating. The differences in some flow rate parameters were significantly different for each of the positions assumed by the children as they emptied their bladder, with girls having a greater peak flow rate and detrusor pressure at the peak urinary flow rate (Qmax) in the sitting position, and boys doing better in the standing position. Overall, girls had a greater Qmax and lower detrusor pressure at Qmax than boys, suggesting that girls void with lower pressure to achieve a greater flow rate than boys, possibly because of lower bladder outlet resistance. In addition, the free flow void (without a catheter) Qmax was greater than with a catheter in both sexes. The authors postulate that the catheter itself, however small, might be obstructive, or its presence might induce some tightening of the external urethral sphincter muscle during the study.

Parâmetros da urofluxometria e do estudo fluxo/pressão em pacientes uroginecológicas

The purpose was to evaluate urine flow rates in an urodynamic study (US) of patients with symptoms of lower urinary tract dysfunction and to record effects of final urodynamic diagnosis and age on these variables. Retrospective analysis of 205 women who had undergone urogynecological investigation. Patients were divided into three age groups: A (< 45 years); B (45 - 60 years) and C (> 60 years). Comportment of urine flow rates and opening detrusor pressure with increasing age were studied and resulting charts recorded. Comparison of maximum and average urine flow rates, opening detrusor pressure and detrusor pressure at the maximal flow according to final urodynamic diagnostic were also made. There was a decline of urine flow rates with increase of age, which was more significant between groups A X C and B X C. There was also a decline in opening detrusor pressure with aging, which was significant between groups A X C. When analyzing opening detrusor pressure according to final urodynamic diagnosis, a significant decline of this variable was observed in patients with urinary stress incontinence and intrinsic sphincter deficiency in relation to those who were asymptomatic. Urine flow rates decreased with age. Women with urinary stress incontinence and intrinsic sphincter deficiency void at a lower detrusor pressure.