Urodynamic assessment of voiding dysfunction and dysfunctional voiding in girls and women

Voiding Dysfunction Due to Urethral Sphincter Dysfunction Might Be an Early Neurological Presentation of Central Nervous System Disorders in Aged Patients

PURPOSE

To investigate the incidence of central nervous system (CNS) diseases in adult patients with voiding dysfunction and videourodynamics (VUDS) proven urethral sphincter dysfunction.

METHODS

This retrospective analysis reviewed the medical charts of patients aged > 60 years who underwent VUDS for non-prostatic voiding dysfunction from 2006 to 2021. A chart review was performed to search for the occurrence and treatment of CNS diseases after the VUDS examination up to 2022. The diagnosis of CNS disease, such as cerebrovascular accidents (CVA), Parkinson's disease (PD), and dementia, by neurologists was also retrieved from the charts. Based on the VUDS findings, patients were divided into the following subgroups: dysfunctional voiding (DV), poor relaxation of the external sphincter (PRES), and hypersensitive bladder (HSB) and coordinated sphincter subgroups. The incidence of CVA, PD, and dementia in each subgroup was recorded and compared among them using one-way analysis of variance (ANOVA).

RESULTS

A total of 306 patients were included. VUDS examinations revealed DV in 87 patients, PRES in 108, and HSB in 111. Among them, 36 (11.8%) patients had CNS disease, including CVA in 23 (7.5%), PD in 4 (1.3%), and dementia in 9 (2.9%). Among the three subgroups, the DV group had the highest incidence rate of CNS disease (n = 16, 18.4%), followed by PRES (n = 12, 11.1%) and HSB (n = 8, 7.2%). However, no significant difference was noted in the incidence of CNS disease across the three subgroups. Nevertheless, the incidence of CNS disease was higher in patients with DV and PRES than that in the general population.

CONCLUSIONS

The incidence of CNS diseases was high in patients aged > 60 years with voiding dysfunction due to urethral sphincter dysfunction. Patients with VUDS-confirmed DV had the highest incidence of CNS disease among the three subgroups.

The Prevalence of Detrusor Underactivity and its Symptoms Co-relation with Urodynamic Study Findings in Patients with Lower Urinary Tract Symptoms

Purpose

This study determines the prevalence and clinical presentation of detrusor underactivity (DU) and its urodynamic characteristics in adult patients with lower urinary tract symptoms (LUTS).

Patients and Methods

This retrospective study has reviewed the symptoms and urodynamic study (UDS) findings of 283 patients with LUTS. Chi-square analysis was used to present the prevalence of UDS characteristics in both sexes.

Results

Out of records of 206 patients included in this study, fifty-one (24.76%) patients were diagnosed with DU based on bladder contractility index. Storage lower urinary tract symptoms were the most prevalent characteristic presentation in both sexes as compared to the difficulty in voiding, recurrent urine retention, and urinary incontinence. Bladder outlet, sphincter EMG findings, and degree of DU were significantly correlated with gender.

Conclusion

DU is a prevalent and sophisticated bladder pathology rather than a simple one. It requires more attention from the urologists, and evaluations, including UDS, to differentiate it from other pathologies.

A Prospective Study to Evaluate the Efficacy of Botulinum Toxin-A in the Management of Dysfunctional Voiding in Women

Objectives:

To assess the outcomes of Botulinum Toxin-A (BoNT-A) to the external urethral sphincter (EUS) in dysfunctional voiding (DV) refractory to standard urotherapy and bowel management.

Methods:

Our criteria to diagnose DV in women included neurologically normal individuals with lower urinary tract symptoms, dilated proximal urethra on voiding cystourethrogram, and high detrusor pressure (PdetQmax > 20 cm H₂O) associated with increased electromyography activity during voiding in urodynamic study (UDS). A total of 16 female patients with a median age of 36 years (5-60 years) received BoNT-A from June 2014 to December 2015. Patients below and above 10 years of age received 100 units and 200 units of BoNT-A to EUS, respectively. Patients were followed up till 6 months.

Results:

Mean AUA (American Urological Association) symptom score decreased significantly from 11.75 ± 6.14 to 5.06 ± 5.1 and 4.25 ± 3.4 at day 14 and day 45 after BoNT-A, respectively (P < .0001). There were no significant improvements in maximal flow (Qmax) on uroflowmetry (UFM) and detrusor pressure at maximal flow (PdetQmax) in UDS. Significant reduction in post-void residual (PVR) from 69.31 ± 77.3 to 17.50 ± 22.3 mL at day 14 (P = .007) was observed, although the reduction was not significant at day 45. Although minor adverse effects were reported, none were serious or life-threatening.

Conclusions:

Our study showed that BoNT-A plays a role in improvement of urinary symptoms and reduces PVR at D14 in DV, but showed no improvement in UFM and urodynamic parameters, albeit with limited numbers and limited follow-up.

Urodynamic characteristics of detrusor underactivity in women with voiding dysfunction

INTRODUCTION AND HYPOTHESIS

Voiding dysfunction has gained interest due to its high prevalence in the elderly. This study characterized bladder dysfunction in women with voiding dysfunction using video urodynamic studies (VUDS) focused on detrusor underactivity (DU).

METHODS

We studied 1914 women in which first-line medical treatment failed. Age, comorbidities, and urodynamic parameters were analyzed to determine the association between bladder sensation and contractility.

RESULTS

VUDS were normal in 2.9% (n = 56) of patients and showed DU in 23.1% (n = 443), detrusor hyperactivity and impaired contractility (DHIC) in 12.0% (n = 231), hypersensitive bladder in 17.0% (n = 325), detrusor overactivity (DO) in 2.6% (n = 49) and bladder outlet obstruction in 42.3% (n = 810). The mean age of patients in the DU and DHIC groups was significantly older than in women with normal VUDS and those with hypersensitive bladders (p<0.01). Decreased bladder sensation and larger cystometric bladder capacity were noted in the DU group compared to the DHIC, HSB, and DO groups. Bladder sensation was negatively associated with the bladder contractility. Bladder contractility index and voiding efficiency were lower in the DU and DHIC groups compared to the normal group.

CONCLUSIONS

The bladder conditions of women with voiding dysfunction included DU, DHIC, HSB and DO. Bladder contractility index and voiding efficiency were significantly lowest in DU and DHIC groups and lower in HSB and DO groups than normal tracing group. Reduced bladder sensation was noted in DU and negatively associated with detrusor contractility.

Videourodynamic analysis of the urethral sphincter overactivity and the poor relaxing pelvic floor muscles in women with voiding dysfunction

AIMS

Voiding dysfunction due to dysfunctional voiding (DV) and poor relaxation of the external sphincter (PRES) are commonly found among adult women with lower urinary tract symptoms (LUTS) during videourodynamic study (VUDS). This study analyzed the VUDS characteristics of DV and PRES in female voiding dysfunction.

METHODS

This retrospective study involved 1914 women aged >18 years with refractory LUTS. The medical records and the VUDS parameters were reviewed. Patients diagnosed with DV and PRES participated in the study. The VUDS characteristics and urethral sphincter activities were compared with those of urodynamically normal women.

RESULTS

Of the 1914 women, 325 (17.0%) and 336 (17.6%) were diagnosed with DV and PRES, respectively. Detrusor overactivity (DO) occurred in 60% of the women with DV and in 5.7% of the women with PRES. Patients with DV had significantly increased bladder sensation, lower cystometric bladder capacity (CBC), lower bladder compliance, higher voiding detrusor pressure, smaller voided volume (VV), larger post-void residual volume (PVR), lower voiding efficiency (VE), and higher bladder outlet obstruction index (BOOI) than the women with PRES and the control individuals. Patients with PRES had significantly increased bladder sensation, lower CBC, lower maximum flow rate, smaller VV, larger PVR, and lower VE than the control individuals.

CONCLUSIONS

DV and PRES were highly prevalent among the adult women with voiding dysfunction. Patients with DV had VUDS characteristics of BOO and urodynamic DO. The clinical symptoms of PRES were similar to those of DV, but the patients had low detrusor contractility and low DO rates.

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.

Toileting behaviours and lower urinary tract symptoms among female nurses: A cross-sectional questionnaire survey

BACKGROUND

Unhealthy toileting behaviours exist among women, and lower urinary tract symptoms have a high prevalence and significant effects on quality of life. However, the relationship between toileting behaviours and lower urinary tract symptoms is unclear.

OBJECTIVES

This study aimed to investigate the prevalence of lower urinary tract symptoms among female nurses, and the association between toileting behaviours and lower urinary tract symptoms.

DESIGN

A cross-sectional stratified cluster sampling study.

PARTICIPANTS

A total of 636 female clinical nurses from tertiary hospitals in Jinan (the capital city of Shandong Province, China).

METHODS

The Toileting Behaviour-Women's Elimination Behaviours and the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms scales were used to assess the participants' toileting behaviours and lower urinary tract symptoms, respectively. Multiple linear regression analysis was used to evaluate the association between toileting behaviours and lower urinary tract symptoms.

RESULTS

Unhealthy toileting behaviours were common among the female nurses, with delayed voiding being the unhealthiest toileting behaviour, which was followed by place and position preference for voiding. Nearly 68% of the female nurses had at least one lower urinary tract symptom, nearly 50% had incontinence symptoms, 40% had filling symptoms, and 18% had voiding symptoms. Unhealthy toileting behaviours (premature voiding, delayed voiding, and straining to void) were positively associated with lower urinary tract symptoms. However, lower urinary tract symptoms were not significantly associated with voiding place or position preference. Among the control variables, being married or having a history of a urinary tract infection was associated with lower urinary tract symptoms. Having a higher income and regular menstrual period were negatively associated with lower urinary tract symptoms. Compared with vaginal delivery, caesarean delivery had a protective association with lower urinary tract symptoms.

CONCLUSION

Lower urinary tract symptoms among female nurses should not be overlooked, because their prevalence among female clinical nurses exceeded that among the general population of women. These findings highlight the importance of avoiding unhealthy toileting behaviours (especially premature voiding, delayed voiding, and straining to void), as these unhealthy toileting behaviours were significantly associated with susceptibility to lower urinary tract symptoms.

Factors associated with fecal incontinence in women with lower urinary tract symptoms

AIM

The aim of this study was to identify the factors associated with fecal incontinence in female patients with lower urinary tract symptoms.

MATERIAL AND METHODS

  Data regarding clinical and urodynamic parameters and history of fecal incontinence of 1334 women with lower urinary tract symptoms who had previously undergone urodynamic evaluation were collected and subjected to univariate, multivariate, and receiver-operator characteristic curve analysis to identify significant associations between these parameters and fecal incontinence.

RESULTS

  Multivariate analysis identified age (odds ratio [OR]=1.03, 95% confidence interval [CI]=1.01-1.05, P=0.005), presence of diabetes (OR=2.10, 95%CI=1.22-3.61, P=0.007), presence of urodynamic stress incontinence (OR=1.90, 95%CI=1.24-2.91, P=0.003), pad weight (OR=1.01, 95%CI=1.00-1.01, P=0.04), and detrusor pressure at maximum flow (OR=1.02, 95%CI=1.01-1.03, P=0.003) as independent risk factors for fecal incontinence. Receiver-operator characteristic curve analysis identified age≥55years, detrusor pressure at maximum flow≥35 cmH(2) O, and pad weight≥15g as having positive predictive values of 11.4%, 11.5%, and 12.4%, respectively, thus indicating that they are the most predictive values in concomitant fecal incontinence.

CONCLUSIONS

  Detrusor pressure at maximum flow and pad weight may be associated with fecal incontinence in female patients with lower urinary tract symptoms, but require confirmation as indicators by further study before their use as screening tools.

Clinical and video urodynamic characteristics of adult women with dysfunctional voiding

BACKGROUND/PURPOSE

Dysfunctional voiding (DV) is an abnormality of bladder emptying in neurologically normal individuals where the external sphincter activity increases during voiding. This study investigated the clinical presentations and videourodynamic characteristics of adult women with DV.

METHODS

A total of 1605 women with lower urinary tract symptoms (LUTS) were investigated with videourodynamic (VUD) studies from 1997 to 2010. The clinical urinary symptoms and VUD characteristics of DV were compared with a group of urodynamically normal controls. Antimuscarinic or alpha-blocker treatment according to the chief complaint of storage or voiding LUTS was respectively given.

RESULTS

There were 168 women diagnosed with DV. Detrusor overactivity (DO) occurred in 69% of women with DV. Patients with DV had significantly lower cystometric bladder capacity, higher detrusor pressure, lower maximum flow rate, and larger post-void residual volume than the controls. A total of 114 (67.9%) patients had storage symptoms and 54 (32.1%) had voiding symptoms as their chief complaints among those with DV. Among them, urinary frequency (n = 69, 41.1%) was the most common chief complaint, followed by dysuria (n = 53, 32.1%), and urgency incontinence (n = 26, 15.5%). The incidence of urgency incontinence and dysuria were significantly greater than that in the control group, however, the incidence of frequency, urgency, or nocturia showed no significant difference between DV and control groups. The success rates were 41.2% (n = 47) for antimuscarinic therapy and 51.9% (n = 28) for alpha-blocker therapy in patients with storage and voiding LUTS, respectively (p = 0.366).

CONCLUSION

DO and storage LUTS commonly occurred in women with DV, suggesting DO could be one of the etiology in the pathophysiology of DV. VUD studies yielded a high diagnostic rate for DV in women with LUTS.

Clinical symptoms are not reliable in the diagnosis of lower urinary tract dysfunction in women

BACKGROUND/PURPOSE

The pathophysiology of female lower urinary tract symptoms (LUTS) may involve bladder, urethral, and pelvic floor dysfunctions. This study analyzed the relationship between clinical symptoms and lower urinary tract dysfunctions (LUTD) in women.

METHODS

A total of 1605 consecutive women were included. LUTS were classified as storage, voiding, pain, and postmicturition symptoms. All patients underwent videourodynamic study (VUDS) and the final diagnosis of LUTD was made based on VUDS findings. Patients were stratified into three major disorder groups: sensory, motor, and bladder outlet disorders. The main symptoms and associated symptoms were used for analysis in varying LUTD.

RESULTS

Normal tracing was found in 272 patients (16.9%), sensory bladder disorders in 459 (28.6%), motor bladder disorders in 560 (34.9%), and bladder outlet disorders were found in 314 patients (19.6%). Frequent urination was the main symptom in patients with normal, bladder oversensitivity, interstitial cystitis, and idiopathic detrusor overactivity (DO). In patients with voiding dysfunction due to detrusor underactivity, bladder neck dysfunction and urethral stricture, dysuria was the most common symptom. However, 707 (44%) of overall women had both storage and voiding symptoms. DO was present in 533 women and in 149 (66%) of 212 with bladder outlet obstruction. However, DO was only found in 42.5% of women with urgency and in 69.4% of women with urgency incontinence based on reported LUTS.

CONCLUSION

Storage and voiding symptoms are common in women with LUTD. The differential diagnosis of LUTD in women cannot be based on LUTS alone.

Changes in urodynamic parameters after tolterodine treatment for female overactive bladder syndrome with or without voiding dysfunction

AIM

To investigate changes in urodynamic parameters after tolterodine treatment for female overactive bladder syndrome, especially in patients with voiding dysfunction.

METHODS

Between January and December 2006, 44 patients were enrolled for six months of treatment with tolterodine. Pre-treatment and post-treatment urodynamic studies were scheduled for the enrolled patients.

RESULTS

Among the remaining 33 patients (11 dropped out), bladder capacity (P < 0.001) and post-void residual urine (P = 0.009) increased, and functional urethral length (P = 0.049) and pad weight test (P = 0.03) decreased after treatment. Besides this, detrusor pressure at maximal urine flow, functional urethral length, maximal urethral pressure and maximal urethral closure pressure were less affected by tolterodine in patients with voiding dysfunction, compared to those without voiding dysfunction.

CONCLUSIONS

Tolterodine treatment increased bladder capacity and decreased urine leakage; however, some urodynamic parameters in patients with voiding dysfunction were less affected by tolterodine treatment.

[Urodynamic study in the female urinary incontinence evaluation, with the new MoniTorr MR system (non-multichannel urodynamic with urethral retro-resistance pressure measure). Experience with 100 patients]

OBJECTIVE

To compare the clinical diagnosis of the urinary incontinence with the results of LPP and URP obtained by non-multichannel urodynamic. To evaluate the tolerance of the patients to this examination.

PATIENT AND METHOD

Between August and December 2006, 100 urodynamics were made in patients with clinical diagnosis of urinary incontinence, in the Urogynecology Unit of Clinica Las Condes. The clinical diagnosis was compared with the urodynamic results. A subjective tolerance scale was applied (0 was greater tolerance and 10 was maximum discomfort).

RESULTS

In 66 patients with clinical diagnosis of IUS, the urodynamic registered 10 Type 0, 2 (I), 23 (II), 1 (III), 17 (II+III), 1 hyperactive detrusor, 5 (0+ hyperactive detrusor). 3 (II+hyperactive detrusor) and 4 (II+III+hyperactive detrusor). In 15 with Mixed urinary incontinence, the urodynamic showed 6 (Type 0), 2 (II), 2 (II+III), 3 hyperactive detrusor, 1 (II+hyperactive detrusor) and 1 (III+hyperactive detrusor). In 16 patients with urgency incontinence, urodynamic showed 2 normal, 4 (II+III), 7 hyperactive detrusor, 1 (II+hyperactive detrusor) and 2 (II+III+hyperactive detrusor). In 3 patients (two vaginal cuff prolapse and one cistocele, degree IV POP-Q) the urodynamic was indicated in the pre-surgery study considering a great potentially incontinence after correction. Respectively, the patients presented: IUS type III+hyperactive detrusor, IUS type II+III and one normal. All patients expressed 2 and 3 degree tolerance (subjective scale: 1 major tolerance and 10 a minor tolerance).

CONCLUSIONS

The MoniTorr MR urodynamic is a complementary examination very useful in the study of the urinary incontinence. It allows planning the solution adapted for each case and has a high degree of tolerance in the patients.

Influence of intravesical potassium on pelvic floor activity in women with overactive bladder syndrome: comparative urodynamics might provide better detection of dysfunctional voiding

OBJECTIVES

To assess the influence of intravesical potassium on pelvic floor activity (PFA) during voiding in women with symptoms of overactive bladder (OAB), by using comparative urodynamics (CUD).

PATIENTS AND METHODS

The study included 175 women who met the criteria of OAB (mean age 52.7 years, range 18-87). CUD included two sessions of pressure-flow studies (0.9% saline vs 0.2 m KCl) with simultaneous measurement of PFA using perineal electromyography (EMG) with surface electrodes. Dysfunctional voiding (DV) was diagnosed if significant PFA was measured by EMG during voiding.

RESULTS

In 44 patients (25%) there was increased EMG activity only in the presence of KCL; in 58 (33%) there was DV with increased PFA during filling with saline. In all these patients PFA was significantly greater in the presence of KCl (P < 0.001). In patients with DV, filling with KCl prompted a statistically significant difference in maximum bladder capacity, maximum flow rate, mean flow rate and postvoid residual urine volume (P < 0.05). In summary, 102 patients (58%) had DV.

CONCLUSION

These findings suggest that DV is associated with epithelial dysfunction of the bladder mucosa, which clinically leads to OAB syndrome and can be revealed by CUD. The detection of DV might elude conventional urodynamics, but can be significantly enhanced by CUD (0.9% saline vs 0.2 m KCl).

Influence of intravesical potassium on pelvic floor activity in women with recurrent urinary tract infections: comparative urodynamics might lead to enhanced detection of dysfunctional voiding

OBJECTIVES

To investigate the influence of intravesical potassium on pelvic floor activity (PFA) during voiding in women with recurrent urinary tract infections (rUTIs) by using comparative urodynamics (CUD).

PATIENTS AND METHODS

CUD was conducted in 49 women (mean age 34.6 years, range 15-82) with rUTI. Every patient had two sessions of pressure-flow studies with simultaneous measurement of PFA by perineal surface electromyography (EMG); the first was with 0.9% saline and in the second the bladder was filled with 0.2 m KCl solution. All patients had voiding cysto-urethrography, and dysfunctional voiding (DV) was diagnosed when significant PFA was measured by EMG during voiding.

RESULTS

Overall, DV was diagnosed in 37 patients (76%) using CUD; 16 (32%) had DV with saline on the pelvic floor EMG. In all these patients there were significantly greater EMG signals in the presence of KCL. In 21 patients (43%) DV was only detected using KCL; this improvement in the detection rate of DV was statistically significant (P = 0.006). Filling with KCl also prompted a statistically significant difference (P < 0.05) in maximum bladder capacity, maximum and average flow rates and in postvoid residual urine volume.

CONCLUSION

The present data show that DV is present in most women with rUTI but cannot sufficiently be diagnosed by conventional urodynamics with standard 0.9% saline. The present study suggests that CUD might enhance the detection rates of DV.

Pathophysiology and subjective symptoms in women with impaired bladder emptying

AIM

To assess the pathophysiology and subjective symptoms in female patients with impaired bladder emptying.

METHODS

Eighty-three consecutive female patients attending a urology clinic with postvoid residual urine of more than 100 mL were recruited. Free uroflowmetry, measurement of postvoid residual urine and pressure-flow study were performed in all patients. The detailed assessment of subjective symptoms and their bothersomeness to the patients were assessed using a self-administered questionnaire comprising 12 items: five associated with voiding symptoms, five with storage symptoms, and two with discomfort and pain on voiding. The questionnaire was applied to 83 patients with impaired bladder emptying, 41 patients with urinary incontinence, and 21 normal controls.

RESULTS

Although 77% of the patients with impaired bladder emptying consulted a urology clinic because of voiding symptoms, the remaining 23% complained of storage symptoms or symptoms other than lower urinary tract symptoms (LUTS). The pressure-flow study revealed the pathophysiology of impaired bladder emptying as impaired detrusor contraction in 68 patients (81.9%), and bladder outlet obstruction in 12 patients (14.8%). The assessment of subjective symptoms using the questionnaire revealed that the patients with urinary incontinence showed a high frequency only in storage symptoms; however, those with impaired bladder emptying revealed a high frequency not only in voiding but also in storage symptoms.

CONCLUSIONS

Female patients with impaired bladder emptying present with a wide range of lower urinary tract symptoms associated with both voiding and storage symptoms. To determine an appropriate treatment modality, the correct diagnosis of the underlying pathophysiology of impaired bladder emptying by pressure-flow study is of primary importance.