Urodynamic morbidity and dysuria prophylaxis

[Antibiotic prophylaxis in urodynamics: Clinical practice guidelines using a formal consensus method]

OBJECTIVE

The aim of this work was to issue clinical practice guidelines on antibiotic prophylaxis in urodynamics (urodynamic studies, UDS).

MATERIALS AND METHODS

Clinical practice guidelines were provided using a formal consensus method. Guidelines proposals were drew up by a multidisciplinary experts group (pilot group = steering group), then rated by a panel of 12 experts (rating group) using a formal consensus method, and then peer reviewed by a reviewing/reading group of experts (different from the rating group).

RESULTS

Urine (bacterial) culture with antimicrobial susceptibility testing is recommended for all patients before UDS (strong agreement). In patients with no neurologic disease, the risk factors for tract urinary infection (UTI) after UDS are age > 70 years, recurrent UTI, and post-void residual volume > 100ml. In patients with neurologic disease, the risk factors for UTI after UDS are recurrent UTI, vesicoureteral reflux, and intermicturition pressure > 40cmH₂O. If the urine culture is negative before UDS and there is no risk factor for UTI, antibiotic prophylaxis is not recommended (Strong agreement). If the urine culture is negative before UDS, but there are one or more risk factors for UTI, antibiotic prophylaxis is optional. If antibiotic prophylaxis is initiated, a single oral dose (3g) of fosfomycin-tromethamine two hours before UDS is recommended (Strong agreement). If there is bacterial colonization on UCB before UDS, antibiotic therapy is optional (Undecided). If prescribed, it should be adapted to the antimicrobial susceptibility of the identified bacterium or bacteria, started the day before and stopped after UDS (except for fosfomycin-tromethamine: a single dose the day before UDS is necessary and sufficient) (Strong agreement). In the event of UTI before UDS, the UTI should be treated and UDS postponed (Strong agreement). The proposed recommendations should not be changed for patients with a hip or knee replacement (Strong agreement). No antibiotic prophylaxis of bacterial endocarditis is necessary, including in high-risk patients with valvular heart disease (Strong agreement).

CONCLUSION

These new guidelines should help to harmonize clinical practice and limit exposure to antibiotics.

LEVEL OF EVIDENCE

4.

Urinary alkalisation for symptomatic uncomplicated urinary tract infection in women

BACKGROUND

Uncomplicated urinary tract infection (UTI) is the most common bacterial infection in women, characterised by dysuria and urinary frequency. Urinary alkalisers are widely used in some countries for the symptomatic treatment of uncomplicated UTI, and they are recommended in some national formularies. However, there is a lack of empirical evidence to support their use for UTI and some healthcare guidelines advise against their use.

OBJECTIVES

We aimed to look at the benefits and harms of the use of urinary alkalisers for the treatment of uncomplicated UTIs in adult women.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Specialised Register to 19 January 2016 through contact with the Trials Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-RCTs on the use of (any) urinary alkalisers (either exclusively or non-exclusively) for the symptomatic treatment of uncomplicated UTI amongst women aged 16 and over, were included. Studies were eligible if they included patients whose diagnosis of UTI was decided by symptoms alone, or positive urine dipstick test or urine culture; and patients with recurrent UTI, provided patients had no symptoms of UTI in the two weeks prior to the onset of symptoms that lead them to seek medical advice. Studies were ineligible if they studied patients with complicated UTIs; immune-compromising conditions; acute pyelonephritis; or chronic conditions such as interstitial cystitis.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed and screened papers, and this was repeated by two separate authors (independently). An additional investigator acted as arbitrator, where necessary. There were no papers which fulfilled the inclusion criteria for this review, and therefore no data extraction was performed.

MAIN RESULTS

Our search identified 172 potential studies for inclusion. However, following assessment none fulfilled the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

Until relevant evidence is generated from randomised trials, the safety and efficacy of urinary alkalisers for the symptomatic treatment of uncomplicated UTI remains unknown.

Does sodium bicarbonate reduce painful voiding after flexible cystoscopy? A prospective, randomized, double-blind, controlled trial

OBJECTIVE

• To determine if sodium bicarbonate (Ural) reduces painful voiding after flexible cystoscopy.

PATIENTS AND METHODS

• 300 patients over 18 years old undergoing elective flexible cystoscopy were enrolled in a randomized, double-blinded, placebo-controlled trial. Patients with active urinary tract infections, indwelling urinary catheters and/or requiring additional procedures such as biopsy and dilatation were excluded. • Painful voiding was quantified using a pain analogue scale from 0 to 10. Pre-existing painful voiding, previous experience with Ural and flexible cystoscopy were recorded. • Flexible cystoscopy was performed to a standard protocol. Patients were randomised after recruitment to receive Ural or placebo (glucose) powder four times a day for two days after the procedure. Trial outcome was assessed by estimating the change in pain incidence and severity from before to two days after by post-procedural questionnaire.

RESULTS

• Painful voiding was present in 84 of the 300 patients post flexible cystoscopy (45 of 160 patients receiving Ural; 39 of 140 receiving placebo), but overall mean pain scores were low (1.25; standard deviation 2.4; on a 0-10 scale). • Treatment with Ural compared to placebo was associated with a non-significant reduction in frequency of pain (28.9% vs 31.3%; incidence rate ratio 0.66; 95% CI 0.29-1.46; P = 0.30) and severity of pain (odds ratio 0.72; 95% CI 0.30-1.74; P = 0.47).

CONCLUSION

•In the replicable context of low post-cystoscopy pain levels, we believe Ural does not reduce painful voiding after flexible cystoscopy.

Morbidity after urodynamic study in diabetic patients

The aim of this prospective study was to evaluate the morbidity of invasive urodynamic study (UDS) in type 2 diabetic patients. Study was conducted on 94 diabetic (59.4 +/- 0.8 years) and 110 non-diabetic (58.1 +/- 0.9 years) patients who had lower urinary tract symptoms. All patients underwent pressure-flow study. The major complication rate after UDS, including urinary tract infection, fever, urinary retention and gross hematuria, was 11.8% for non-diabetics and 22.3% for diabetics (p = 0.044). No significant differences were found between diabetics and non-diabetics according to gender with respect to dysuria, hematuria and pain (p > 0.05). Existence of pyuria before UDS was significantly higher in diabetic women with major complication than without major complication (p = 0.011). On the other hand, residual urine volume (p = 0.004) and diabetic cystopathy (0.005) were found significantly higher in diabetic men with major complication than without major complication. Our study demonstrated that UDS has an important role on the occurrence of high objective and subjective morbidity in diabetic and non-diabetic patients. Therefore, UDS indication should be carefully evaluated, especially in diabetic men who have high residual urine volume and diabetic women who have pyuria before UDS.

Is antibiotic prophylaxis in invasive urodynamics a useful procedure in postmenopausal subjects?

Objectives.

To define the incidence rate of urinary tract infections (UTI) and the usefulness of antibiotic prophylaxis in postmenopausal female undergoing invasive urodynamics (IU).

Methods.

262 postmenopausal females underwent IU, being previously double-blindly randomized in 2 homogenous age-matched groups. Group 1 (130 patients) received oral antibiotic prophylaxis with a single 400 mg dose of norfloxacin. Group 2 (132 patients) was given placebo. The statistical analysis was performed using a Chi-Square test, in order to evaluate any difference between groups for UTI incidence rate.

Results.

54 patients out of 262 (20.6%) developed a UTI [24 out of 130 subjects who received antibiotic prophylaxis (18.4%), and 30 out of 132 subjects who received placebo (22.7%)]. As per the UTI incidence rate, no statically significant difference (p>.05) was shown between patients receiving and those not receiving the antibiotic prophylaxis.

Conclusions.

The UTI incidence rate in postmenopausal women undergoing urodynamics is not affected by the administration of antibiotic prophylax.

Rising PSA in patients with minor LUTS without evidence of prostatic carcinoma: a missing link?

OBJECTIVES

To determine the role of pressure flowmetry in patients without bothersome lower urinary tract symptoms (LUTS), rising prostate-specific antigen (PSA) levels and diagnosed as having clinical benign prostatic hyperplasia (BPH) after negative (multiple) extended multi-site biopsy.

METHODS

The study enrolled patients with minor LUTS who were referred to our urological practice by their general practitioner because of a rising PSA level (>/=4 ng/ml). After exclusion of clinical prostatic carcinoma by digital rectal examination and transrectal ultrasound, all patients underwent at least one set of extended multi-site biopsies to exclude T1c prostate cancer. Patients with negative biopsies (clinical BPH) were subjected to pressure flowmetry whereafter those with bladder outlet obstruction underwent TURP.

RESULTS

The study included 82 patients, with a mean age of 64.8 years (50.2-78.2 years), satisfying the inclusion criteria. Urodynamic analysis showed that all patients had bladder outlet obstruction. After TURP, eight patients (9.8%) were diagnosed as having histologically proven prostate cancer; 74 patients (90.2%) were diagnosed as having BPH. Patients of the BPH group had a mean preoperative PSA level of 8.8 ng/ml (4.3-25.8 ng/ml) and a mean international prostate symptom score of 8.8 (2-18). The mean detrusor pressure at maximum flow in BPH patients was 89.5 cmH(2)O (20-200 cmH(2)O).

CONCLUSIONS

An increased PSA in patients with minor or no LUTS, clinical BPH and negative extended multi-site prostate biopsy is strongly correlated to bladder outlet obstruction. Therefore, patients with these characteristics should be treated with TURP.

Clinical relevance of urodynamic investigation tests prior to surgical correction of genital prolapse: a literature review

Urodynamic investigations have been advocated to be incorporated in the standard diagnostic workup of patients undergoing surgical correction of genital prolapse. Stress incontinence is reported by 40% of patients with genital prolapse. Urodynamic stress incontinence (USI) is diagnosed in 70-75% of these patients. Occult urodynamic stress incontinence (OUSI) is diagnosed in about 50% of the patients with genital prolapse not reporting stress incontinence before surgery. Performing urodynamic investigation in patients undergoing prolapse surgery may be valuable if diagnosing USI or OUSI results in the selection of the optimal treatment strategy. This treatment strategy is either a combination of prolapse and stress incontinence surgery or prolapse surgery at the beginning and re-evaluation of possible stress incontinence afterwards. The combination of prolapse and stress incontinence surgery has the advantage of attempting to solve two problems at the same moment, but carries an increased risk on unwanted side-effects, of which, voiding dysfunction and detrusor overactivity are the most important. This review presents a literature overview of what has been proven about the diagnostic and therapeutic value of urodynamic investigations in patients undergoing prolapse surgery.

Effectiveness of ciprofloxacin prophylaxis in preventing bacteriuria caused by urodynamic study: A blind, randomized study of 192 patients

OBJECTIVES

To determine the efficacy of prophylactic ciprofloxacin in preventing urinary tract infections caused by urodynamic study (UDS).

METHODS

A total of 210 patients presenting for UDS during a 16-month period were offered enrollment in the study. A clean-catch midstream urine sample was taken 24 hours before and 48 to 72 hours after the procedure and after microscopic examination and culture were done. All patients underwent a standard UDS. The 192 patients who had sterile urine before intervention were included in the study. Randomly, 98 of the 192 patients were orally given 500 mg of ciprofloxacin 1 hour before the urodynamic intervention and 94 were not given anything. The patients who were found to have significant bacteriuria after UDS were followed up and treated properly.

RESULTS

Eighteen patients (8.6%) who had significant bacteriuria in the urine culture before UDS were excluded from the study. The rate of significant bacteriuria in the urine culture after UDS was 7.3% overall, 1% in the prophylaxis group, and 14% in the controls, a significant difference (P = 0.002). The most common uropathogen was Escherichia coli (57%). Three independent risk factors were identified: not giving antibiotic prophylaxis before UDS; antibiotic use in the preceding month; and the presence of pyuria before UDS.

CONCLUSIONS

Urinary tract infections after UDS decreased from 14% to 1% with a single dose of ciprofloxacin 500 mg orally before UDS. We recommend antibiotic prophylaxis for patients undergoing a UDS.

Patient perception of videourodynamic testing: a questionnaire based study

PURPOSE

We determined the degree of anxiety, embarrassment and discomfort anticipated by patients before undergoing videourodynamics and compared the results to the actual degrees experienced by patients. In addition, we compared these variables between men and women, and younger and older patients.

MATERIALS AND METHODS

All patients undergoing urodynamics for the first time were given a 2 part questionnaire. Patients with neurological disease or those requiring an indwelling or intermittent catheter were excluded. Part 1 given immediately prior to the test contained 5 questions regarding expected anxiety, pain, embarrassment, apprehension regarding x-ray exposure and preparedness. Part 2 given immediately after testing contained 5 questions comparing anticipated to actual overall experience, pain and embarrassment, preparation and whether the patient would undergo testing again. Each question had a 5 point scale.

RESULTS

A total of 78 men and 88 women respondents completed the questionnaires. Most (greater than 95% per question) expected no to moderate anxiety, pain, embarrassment and apprehension. This did not vary with age, although more women anticipated greater embarrassment and more men expected little or no embarrassment (p <0.001). After testing most respondents (greater than 90% per question) thought that the test was the same or better than expected and it was associated with an expected or less than expected level of pain and embarrassment. This did not vary between the sexes but more younger individuals found that the test experience was worse than expected, while more older individuals found that it was better than expected. Of the patients 95% would undergo urodynamic testing again if medically indicated.

CONCLUSIONS

Videourodynamics is well tolerated and is associated with only minimal to moderate degrees of anxiety, discomfort and embarrassment. A suspected lack of tolerance should not be a barrier to performing medically indicated urodynamic testing.

Utility of urine reagent strip in screening women with incontinence for urinary tract infection

The aim of this study was to determine the utility of urine reagent strips in screening women with urinary incontinence for urinary tract infections. Subjects were all women presenting with urinary incontinence. A urine specimen was screened for urinary tract infection with a urine reagent strip and urine culture. Using the urine culture result as the gold standard, the sensitivity, specificity, and positive and negative predictive values of the urine reagent strips were calculated. A total of 265 pairs of reagent strips and urine cultures were evaluated. Thirty-one cultures grew out of a single organism; nine of these had a positive urine reagent strip, yielding a sensitivity of 29%. The specificity of the urine reagent strip was 99%, the positive predictive value was 82% and the negative predictive value was 92%. For women presenting with urinary incontinence, the sensitivity of a urine reagent test for diagnosing urinary tract infection was low.

Voiding dysfunction and urodynamic abnormalities in elderly patients

Lower urinary tract dysfunction is a major cause of morbidity and decreased quality of life in elderly men and women. With the progressive aging of the population, it is important to understand common micturitional disorders that may occur in this population. Most urinary problems in the elderly are multifactorial in origin, demanding a comprehensive assessment of the lower urinary tract organs, functional impairments, and concurrent medical diseases. Urodynamics is a highly valuable tool in the investigation of elderly patients with lower urinary tract symptoms. Urodynamic tests are not always necessary, being indicated after excluding potentially reversible conditions outside the urinary tract that may be causing or contributing to the symptoms. Although urodynamic tests may reveal common diagnoses such as bladder outlet obstruction and stress urinary incontinence in the elderly population, findings such as detrusor overactivity and impaired detrusor contractility are common and have important prognostic and therapeutic implications. The purpose of this article is to describe common urologic problems in the elderly and review the indications for and clinical aspects of urodynamic studies in these conditions.

Morbidity after ambulatory urodynamics

AIMS

To identify urinary symptoms and morbidity after ambulatory urodynamics.

METHODS

One hundred consecutive women underwent ambulatory urodynamics for a variety of urinary complaints. Urinary symptom questionnaires were collected before investigation and again 48 hours later, reporting dysuria and haematuria. Women were screened for urinary tract infection before investigation and again 48 hours later.

RESULTS

Of the 91 women who completed the study, 1 (1.1%) had a positive urinary culture after the investigation but was asymptomatic. Seventeen women reported mild to moderate de novo dysuria.

CONCLUSIONS

Urinary symptoms and morbidity after ambulatory monitoring is low.

Quality control in urodynamics: a review of urodynamic traces from one centre

OBJECTIVE

To investigate quality control in our unit and to enable other units to compare their results, as experience from central reviews of urodynamic traces for multicentre trials has suggested that poor quality control is common.

PATIENTS AND METHODS

All consecutive male urodynamic tests conducted over 1 year were reviewed. A list of criteria to assess the quality of the records was devised, based upon International Continence Society guidelines on "good urodynamic practice", and on other sources. Eligible traces were analysed for aspects of quality control, e.g. baseline pressures and coughs to test pressure transmission. The data were analysed to establish how often quality criteria were met, and identify areas for improvement.

RESULTS

In 100 eligible traces, the baseline detrusor pressure was 0-10 cmH2O in 86, and - 5 to +10 cmH2O in 94%. Baseline intravesical and abdominal pressure were 30-50 cmH2O in 68% and 73% of cases, respectively. Coughs were present before filling in 94%, during filling in 95%, before voiding in 72% and after voiding in 87% of cases. The cough-test frequency was sufficient in 30% of traces. In 11 the intravesical pressure line fell out during voiding.

CONCLUSION

Most of the traces assessed met the quality criteria defined, but significant defects were not uncommon. Some of the problems identified suggest areas of urodynamic technique which should be studied in more detail. We intend to modify our quality control practices, and hope to show an improvement on re-audit. We hope that other urodynamic departments will be encouraged to review their practice, and we aim to improve our results.

Urinary tract infection and patient satisfaction after flexible cystoscopy and urodynamic evaluation

OBJECTIVES

To investigate the incidence of symptomatic and asymptomatic bacteriuria and to assess patient satisfaction after flexible cystoscopy (FC) and urodynamic (UD) evaluation in a prospective survey. The incidence of urinary tract infection after FC and UD studies and the use of prophylactic antibiotics are issues of debate. The tolerability and acceptance of FC and UD studies by patients have not been thoroughly documented. It would be helpful to be able to give such information to patients before performing these procedures.

METHODS

A total of 215 nonconsecutive patients seen as outpatients for FC and UD studies to evaluate various indications were studied. A midstream urine sample was taken before and 48 hours after the procedures. Patients were given a questionnaire that inquired about the presence of lower urinary tract symptoms before and 48 hours after the procedures. The self-administered questionnaire included questions to assess patients' tolerance of the procedures and how it compared with their expectations.

RESULTS

Of the 201 patients analyzed (FC 103, UD studies 98), 9 patients (4. 5%) developed significant bacteriuria within 48 hours of FC and UD studies. Only 2 patients with significant bacteriuria reported newly developed symptoms within 48 hours. In a subgroup of 25 patients who were given prophylactic antibiotics for various reasons, 6 (24%) reported new symptoms, although none developed significant bacteriuria. The association between patients who had preprocedure pyuria (n = 7) and the development of significant growth after the procedure (n = 6) was significant (P <0.01). In response to the patient-satisfaction questionnaire, 166 (82.5%) reported that the procedure was not as bad as they expected, and 200 (99.5%) said that they would undergo the test again if necessary.

CONCLUSIONS

FC and UD studies are safe, well-tolerated procedures. The addition of prophylactic antibiotics in these procedures is unnecessary, unless specific indications are present.

The relative incidence of detrusor instability and bacterial cystitis detected on the urodynamic-test day

OBJECTIVE

To determine whether patients with detrusor instability (DI) were more likely to have bacterial cystitis or significant bacteriuria on the urodynamic-test day than were women with a stable bladder.

PATIENTS AND METHODS

A catheter specimen of urine was cultured (overnight in air) from 862 consecutive women at the time of urodynamic testing. The upper urinary tract was imaged, with cystoscopy when indicated, to exclude upper tract lesions or malignancy. The percentage of patients with pure idiopathic DI and those with mixed DI/genuine stress incontinence (GSI), in whom the urine culture was positive, was compared with the percentage who had a stable bladder (pure GSI or urodynamically normal) and a positive urine culture, both for the entire dataset and for women aged > or <65 years. Data were also analysed to detect the converse relationship; in those women found to have bacterial cystitis, the relative risk of being found urodynamically unstable or stable was determined.

RESULTS

The likelihood of bacterial cystitis occurring in patients with idiopathic DI (5.6%) was significantly greater than that in patients with GSI (1.1%; P = 0.009, Fisher's exact test). The proportion of patients with DI and significant bacteriuria (15. 4%) was significantly greater than that in patients with GSI (7.9%; P = 0.02). In patients with combined pure and mixed DI, bacterial cystitis was significantly more likely to occur (6.3%) than in GSI (P < 0.001), but bacteriuria was no more likely (12.5%, P = 0.09). Conversely, of those women found to have bacterial cystitis, the relative risk of having an unstable bladder was increased (+1.56), but for those with bacteriuria the relative risk of detrusor instability was not increased.

CONCLUSION

There was a significant association between idiopathic DI and bacterial cystitis, and we suggest that in some women with an unstable bladder, urinary infection may enhance detrusor contractility. Nevertheless, large-scale studies are needed of the temporal relationship between the onset of bacterial cystitis and the onset of DI.

Assessment and investigations for urinary incontinence

Assessment of a woman complaining of urinary incontinence includes full urological, gynaecological, medical, surgical and drug histories. General, neurological, abdominal and pelvic examinations are undertaken and with the history, enable a presumptive diagnosis to be formulated. Investigations for incontinence should be selected to suit the individual woman's need. Non-specialist investigations include urine testing, completion of a urinary diary and symptom score, pad testing, measurement of residual urine volume and biochemical tests. Specialist investigations include uroflowmetry, conventional and ambulatory cystometry, urethral pressure profilometry and measurement of urethral electrical conductance and leak point pressure. Imaging using ultrasound, X-ray, magnetic resonance or isotopes is sometimes indicated. While neurophysiological testing has little clinical application, cystourethroscopy is of value in various subgroups of women. Thorough assessment and appropriate investigation together result in an accurate diagnosis which in turn allows appropriate treatment for urinary incontinence to be initiated.

Evaluation of morbidity of multi-channel pressure-flow studies

This prospective study was carried out to evaluate the morbidity and complication rate of invasive urodynamics of the lower urinary tract after receiving oral antibiotic prophylactic treatment. A total of 105 patients, 55 men and 50 women, were included in the study and underwent pressure flow study (PFS) as part of the diagnostic assessment. Clinical diagnosis was prostatic obstruction from benign prostatic hyperplasia (BPH) in men and stress urinary incontinence or voiding dysfunction in women. Urine was screened for infection both before and after testing, and the incidence of urinary tract infections (UTI), dysuria, and other complications were assessed at 1-week follow-up to evaluate post-investigation morbidity. Dysuria of mild degree was experienced by 33% of patients, with no significant difference between male and female patients. Post-investigational UTI and fever were reported in 3.6% of men and 4% of women. Six patients had macroscopic hematuria of mild degree. No patient had urinary retention or severe complaints after the investigation and no patient required hospitalization. Post-void residual volume was higher in men with BPH obstruction compared to women; a significant difference between post-investigational UTI and residual volume could not be demonstrated (P = 0.8). We conclude that the objective morbidity rate of invasive urodynamic investigation is low. Mild dysuria is common, while severe complications, fever, and hematuria are seldom reported, and the risk of developing UTIs is low with antibiotic prophylaxis, with no significant difference between men and women. Neurourol. Urodynam. 18:647-652, 1999.

The tolerability of urodynamic studies and flexible cysto-urethroscopy used in the assessment of men with lower urinary tract symptoms

OBJECTIVE

To determine the overall tolerability of urodynamic studies used in the assessment of men with lower urinary tract symptoms (LUTS), by assessing the objective and subjective morbidity experienced during and after urodynamic studies, and to assess the voiding complaints caused by the combination of urodynamic studies with flexible cysto-urethroscopy.

PATIENTS AND METHODS

A total of 103 men with LUTS, who underwent a urodynamic study combined with flexible cysto-urethroscopy, completed a questionnaire designed to assess objective and subjective symptoms and degree of bother, with emphasis on the urodynamic study. In addition, a urine specimen was analysed and cultured. In all, 78 patients who underwent a second urodynamic study completed the questionnaire twice.

RESULTS

The results of the first questionnaire showed that more than half of the patients experienced some urge after the urodynamic study and cysto-urethroscopy (56%); 35% of the patients experienced little and 19% experienced severe voiding discomfort after the combined investigations, compared with 24% and 5%, respectively, after a urodynamic study alone. Three patients (3%) had a symptomatic urinary tract infection. Haematuria, increased voiding frequency and increased nocturia occurred occasionally. Most of the patients found the urodynamic study less bothersome than they had expected (64%) and only 9% found it worse than expected. The overall degree of discomfort, experienced during and after the urodynamic study combined with cysto-urethroscopy, was low, and after a second urodynamic study was even lower.

CONCLUSION

In contrast with earlier results, this clinic-based urodynamic investigation was associated with a low proportion of urinary tract infection, and low objective and subjective morbidity. The combination of a urodynamic study with a flexible cysto-urethroscopy does not cause significant additional voiding complaints. Most patients find urodynamic studies tolerable and not very bothersome.

Lack of morbidity from urodynamic studies in children with asymptomatic bacteriuria

OBJECTIVES

Patients on clean intermittent catheterization (CIC) have a high rate of asymptomatic bacteriuria. Although prophylactic antibiotics for routine surgical procedures in patients with bacteriuria is common practice, the role of prophylaxis for invasive diagnostic procedures remains unclear. The aim of this study was to investigate the morbidity associated with urodynamic evaluation in patients with asymptomatic bacteriuria.

METHODS

Routine urodynamic evaluation was performed in 69 pediatric patients (mean age 10 years). Ninety-six percent had a neurogenic bladder, and most were on CIC. Routine urine cultures were obtained at the time of the cystometrogram. Forty-six patients had positive urine cultures, and 23 patients with sterile urine served as a comparison. Patients were evaluated subjectively for symptoms of a urinary tract infection (UTI) within 1 week of the procedure. The results of the cystometrograms were compared between the patients with and without bacteriuria.

RESULTS

No patient developed symptomatic UTI after the urodynamic studies. Overall, 65% of the patients with and 52% of the patients without bacteriuria had adequate capacity and compliance, and there was no difference in the urodynamic findings between the patients with and without bacteriuria (P = 0.4).

CONCLUSIONS

Urodynamic studies were performed safely in the presence of asymptomatic bacteriuria in the present study. Therefore, routine use of urine cultures or prophylactic antibiotics before urodynamic studies in pediatric patients with a neurogenic bladder does not appear to be indicated.

Women's attitudes to urodynamics: a questionnaire survey

OBJECTIVE

To obtain a measure of how well women tolerate urodynamic investigations and to determine how well they thought the test was explained.

DESIGN

Prospective questionnaire survey.

SETTING

A teaching hospital tertiary referral centre urodynamic laboratory.

PARTICIPANTS

Three hundred and twenty-four women attending for urodynamic investigations on 331 occasions. Questionnaires were returned from 297 women (91.7%) with six women returning two questionnaires.

RESULTS

Urodynamic investigations were well tolerated by most women, with 45% feeling that the procedure was not as bad as they expected. Moderate or severe anxiety about the test was experienced by 42% and 40% felt moderately or severely embarrassed. Pain was noted by 27% of women during investigation, and by 13% after investigation. Overall distress from the procedure was less in older women and in those who had been referred from a specialist urogynaecology clinic. Distress was higher when difficulties were encountered during the investigation and in women who had investigations other than a standard cystometrogram. Women were likely to find the test less distressing when they felt they had been given adequate information about the test.

CONCLUSIONS

Although urodynamic investigations are generally well tolerated, there is a significant minority of women who find the test embarrassing, painful and distressing.

Urinary tract infection after urodynamic studies in women: incidence and natural history

OBJECTIVE

To study the incidence, natural history and symptomatic effects of bacteriuria after urodynamic studies in women.

PATIENTS AND METHODS

In a prospective study in the urogynaecology clinic of a large District General Hospital, 214 women (mean age 52.3 years, range 23-81) underwent urodynamic studies. Bacteriuria was detected by semiquantitative culture at 2 and 7 days after the test. Women completed a 7-day diary of symptoms and events.

RESULTS

The incidence of bacteriuria after urodynamic studies was 7.9%. Bacteriuria was transient in four of 17 women but persisted in nine and developed late in four; only one of 17 infections gave rise to symptoms. Irritative bladder symptoms after the test occurred in 34% of women, but only three went to their doctors because of concern about a possible urinary tract infection. Advancing age was the only variable associated with bacteriuria after urodynamic studies (P= 0.05). Menopausal status, past history of urinary tract infection, number of urethral instrumentations required, order number in a session, peak urinary flow rate and urodynamic diagnosis were not associated variables.

CONCLUSIONS

In a large series of women presenting to a urogynaecology clinic, urodynamic investigations were associated with a high incidence of transient irritative symptoms but a low incidence of bacteriuria (8%). Infection was asymptomatic in most patients, but its natural history was unpredictable. Transient, persistent and late cases of bacteriuria all occurred. In this population, urodynamic studies are associated with a low level of morbidity.

Morbidity of the evaluation of the lower urinary tract with transurethral multichannel pressure-flow studies

PURPOSE

The aim of this prospective study was to determine morbidity and complication rate of invasive urodynamic evaluation of the lower urinary tract after transurethral multichannel pressure-flow studies.

MATERIALS AND METHODS

The study included 63 men with the clinical diagnosis of benign prostatic hyperplasia and 56 women with stress urinary incontinence. All patients underwent routine pressure-flow study as part of the urodynamic evaluation. A week later the patients returned for followup which also included a detailed interview on post-evaluation morbidity.

RESULTS

The overall complication rate, including urinary retention, gross hematuria, urinary tract infection and fever, was 19.0% (12 of 63) for men and 1.8% (1 of 56) for women. In men there was no statistically significant correlation between post-void residual urine or age and complication rate (p > 0.05). Of the men 4.8% experienced post-investigational urinary retention and all of them had significant bladder outflow obstruction. In addition, obstructed men reported a higher incidence of dysuria and pain (76.2%, 32 of 42) compared to those without obstruction (57.1%, 12 of 21), whereas only 53.6% of women reported these complaints. Of the 63 men 4 (6.2%) had significant urinary tract infections, while only 1 woman (1.8%) had infections.

CONCLUSIONS

Invasive urodynamic investigation is associated with a considerable rate of complications and morbidity, particularly in men with infravesical obstruction. These facts must be considered and discussed with the patient before urodynamic testing.

Ultrasound: a noninvasive screening test for detrusor instability

OBJECTIVE

To determine whether transvaginal ultrasound measurement of bladder wall thickness can be used as a screening test for detrusor instability in women with urinary symptoms.

DESIGN

A blinded prospective study.

SETTING

A London teaching hospital.

PARTICIPANTS

One hundred and eight-four symptomatic women presenting to a urodynamic clinic.

MAIN OUTCOME MEASURE

The detection of detrusor instability by means of videocystourethrography (VCU) and ambulatory urodynamics in women with a mean bladder wall thickness of greater than 5 mm measured by transvaginal ultrasound.

RESULTS

One hundred and eight women had a mean bladder wall thickness of greater than 5 mm. Ninety-four percent (102) of these women had detrusor instability either when undergoing VCU or ambulatory urodynamics. Seventeen women had a bladder wall thickness of less than 3.5 mm of whom three were found to have detrusor instability on VCU.

CONCLUSION

The measurement of a mean bladder wall thickness greater than 5 mm with transvaginal ultrasound is a sensitive screening method for diagnosing detrusor instability in symptomatic women without outflow obstruction.

A combined urodynamic and continence unit--a review of the first 19 years

We have completed a 19-year audit of all patients referred to the urodynamic/continence unit since its inception in 1972 and their subsequent clinical management; a total of 20,437 patients were referred, increasing from 51 in the first year to 1564 in 1990. Although the annual number of referrals has remained constant for the last 8 years, the need for more complex urodynamic assessment such as video-cystourethrography has increased from 5% (56/1164) in 1981 to 25% (385/1564) in 1990. The number of out-patient attendances to medical, physiotherapy and continence clinics has also increased over that period. We conclude that the number of referrals represents increasing recognition of the value of urodynamic assessment. Accurate diagnosis leads to more effective treatment, whether surgical, medical or conservative. Some methods of diagnosis are complex and suitable only for a tertiary referral centre.