Impaired bladder emptying in women

Validation of a Chinese version for the global Pelvic Floor Bother Questionnaire

PURPOSE

The Pelvic Floor Bother Questionnaire (PFBQ) is a self-administered instrument for determining pelvic floor dysfunction (PFD). The PFBQ was validated in English, but lately in other languages. However, a Chinese version has not been established. Thus, we aimed at validating a Chinese PFBQ version.

METHODS

We used a translation-back method to develop a PFBQ Chinese version and validated in 102 women, 51 with at least one PFD symptom participated in the patient group, and 51 without PFD in the control group. Construct validity was assessed by comparing groups and a content validity index (CVI) determined. For test-retest reliability, participants completed the questionnaire twice within 1-week interval and the interclass correlation coefficient (ICC) was determined. Internal consistency was calculated using Cronbach's statistics.

RESULTS

Missing information after applying the translated PFBQ did not exceed 4% of any questions. Total scores between control and PFD women were significantly different (2.94 ± 1.84 vs. 10.29 ± 6.64; P < 0.001). The CVI for all items ranged from 0.800 to 1.000, and a good reliability was corroborated (α = 0.677, ICC = 0.938).

CONCLUSION

The Chinese PFBQ version is a valid and reliable tool to identify the existence and severity of bothersome symptoms in Chinese women with PFD.

Voiding dysfunctions in patients with non-Hunner's ulcer interstitial cystitis/bladder pain syndrome do not affect long-term treatment outcome

PURPOSE

The role of urodynamic study in the diagnosis and prognostication of interstitial cystitis/bladder pain syndrome (IC/BPS) is still controversial. This study evaluated the correlation of the baseline voiding dysfunctions and long-term treatment outcome in patients with non-Hunner's ulcer IC (NHIC).

MATERIALS AND METHODS

A total of 211 NHIC patients were enrolled. All patients underwent videourodynamic (VUDS) examination at baseline to identify their voiding conditions and received subsequent treatments. The primary endpoint was Global Response Assessment (GRA) at the interview. Secondary endpoints included O'Leary-Sant symptom score (OSS), Visual Analogue Scale (VAS) for pain and the rate of IC symptom flare-up.

RESULTS

The mean age was 56.8 ± 12.8 years, and mean duration of IC was 16.0 ± 9.9 years. At baseline, 83 (39.3%) patients had a voiding dysfunction and 132 (62.7%) had 1 to 3 co-morbidities. The duration, co-morbidities, treatments, changes in OSS and VAS, maximum bladder capacity (MBC), glomerulations, GRA and flare-up rate showed no significant difference among different subgroups. When we divided patients by their storage and voiding conditions, patients with non-hypersensitivity bladder (HSB) (n = 32) had significantly greater MBC (P = .002) whereas those with HSB with (n = 76) or without (n = 103) voiding dysfunction had higher glomerulation (P = .021). When we analysed voiding dysfunction subgroups by GRA, patients with a GRA of ≥2 had a significantly shorter duration of disease (13.9 ± 8.6 years, P = .021). There were also significant associations between GRA and the changes of OSS (P < .001) and VAS (P < .001).

CONCLUSIONS

VUDS can disclose voiding dysfunction in 39.3% of NHIC patients. With adequate therapy, the voiding dysfunctions in NHIC patients do not affect long-term treatment outcome.

Medium-term effects on voiding function after pelvic reconstructive surgery of advanced pelvic organ prolapse: Is postoperative uroflowmetry necessary?

OBJECTIVE

To evaluate the necessity of postoperative repetitive uroflowmetry and postvoid residual volume (PVR) in women with advanced anterior vaginal prolapse.

METHOD

Women with anterior vaginal prolapse stages III and IV who underwent surgery were included in this prospective cohort study. The surgical procedures included laparoscopic sacrocolpopexy (LSC), transvaginal mesh repair (TVM) and native tissue repair (NTR). Uroflowmetry, a PVR examination, the Urinary Distress Inventory-6 (UDI-6) and the Urinary Impact Questionnaire-7 (UIQ-7) were administered pre- and postoperatively. Moreover, pre- and postoperative uroflowmetry parameters were compared in women with/without an improvement in voiding difficulties according to the answer of questionnaires at one year after surgery. Paired sample t-tests, Wilcoxon signed-rank test, χ2 tests were used for analyses.

RESULTS

A total of 85 women were included in the study, and data were available for 47 of them at 1-year follow-up. Approximately half of women with advanced anterior vaginal prolapse had symptoms of voiding dysfunction, the rate of which decreased to approximately 10% postoperatively. The UDI-6 and UIQ-7 indicated a significant improvement postoperatively from baseline (both p<0.05). The PVR decreased significantly after surgery (p = 0.000). Uroflowmetry parameters remained stable within 1 year after surgery (all p＞0.05) both in the improved and unimproved groups (both p＞0.05).

CONCLUSION

Symptoms of voiding dysfunction are improved significantly after surgery. Postoperative uroflowmetry appears to be unnecessary one year after pelvic floor reconstructive surgery.

Uncommon cause of voiding dysfunction in a female patient-vaginal abscess: A case report

BACKGROUND

Vaginal abscess is a treatable disease and should be considered in female patients with voiding difficulties and perineal tenderness. There are no reported cases of vaginal abscess causing voiding dysfunction in the absence of a previous surgery. Early diagnosis and drainage of vaginal abscesses may lead to excellent outcomes.

CASE SUMMARY

We presented a case of vaginal abscess that caused voiding dysfunction without surgery history. A 64-year-old woman had a past history of type 2 diabetes mellitus. She came to our clinic following urinary difficulty with perineal tenderness. Bladder ultrasonography revealed a pelvic cystic lesion with a mass effect on the bladder. The presence of a vaginal abscess was suspected following pelvic examination and transvaginal ultrasound. After transvaginal drainage of the vaginal abscess and a full course of antibiotic treatment, she recovered well without any urination symptoms.

CONCLUSION

Voiding dysfunction caused by vaginal abscess is rare but should be considered in female patients with perineal tenderness.

Current concepts in voiding dysfunction and dysfunctional voiding: A review from a urogynaecologist's perspective

BACKGROUND

Female voiding dysfunction is a complex disorder, lacks definition, and is poorly understood and difficult to manage.

CAUSES OF FEMALE VOIDING DYSFUNCTION

As there is no agreed classification of female voiding dysfunction, it is important to identify the several potential factors that might cause voiding dysfunction, namely anatomic, neurogenic, pharmacologic, endocrine, pharmacological and other causes.

PRESENTATION AND CLINICAL EVALUATION

Traditional and novel techniques are available and the importance and diagnostic dilemma related to these conditions need to be understood. We conclude by emphasizing the need to simplify the diagnosis and nomenclature of these conditions from a more clinical point of view as against an investigational perspective.

Effect of aging on storage and voiding function in women with stress predominant urinary incontinence

PURPOSE

We investigated age related changes in urodynamic parameters in 2 large cohorts of women planning stress urinary incontinence surgery.

MATERIALS AND METHODS

Using a standardized protocol we obtained urodynamic parameters for participants in SISTEr (Stress Incontinence Surgical Treatment Efficacy Trial) and TOMUS (Trial of Mid-Urethral Slings) undergoing baseline noninvasive flow followed by filling cystometrogram and pressure flow study. The bladder contractility index (defined as detrusor pressure at maximum flow+5×maximum flow) and detrusor hypocontractility (defined as detrusor pressure at maximum flow less than 10 cm H2O) were also characterized. Patients excluded from analysis had undergone prior stress urinary incontinence surgery or had prolapse stage greater than II. Propensity score analysis controlled for the potential bias of combining participants from 2 clinical trials. Linear and logistic regression analysis adjusting for propensity score quintile was done to assess the association of age and an age cutoff (less than 65 vs 65 or greater years) with urodynamic parameters.

RESULTS

A total of 945 women (468 in SISTEr and 477 in TOMUS) were included in analysis. Mean age was 50 years in SISTEr (range 27 to 75) and 51 years (range 24 to 82) in TOMUS. Noninvasive maximum urinary flow decreased significantly with age (26.2 vs 22 ml per second, p=0.002). Noninvasive flow voiding time increased 2.7 seconds for each 10-year age increment and detrusor pressure at maximum flow decreased 2.1 cm H2O for each 10-year increase in age (each p=0.003). Hypocontractility was more likely in women 65 years old or older (OR 2.89, 95% CI 1.59, 5.27). The bladder contractility index was inversely related to age, decreasing a mean±SD of 7.68±1.96 cm H2O for each 10-year age increase (p<0.001).

CONCLUSIONS

In these 2 cohorts the observed changes in voiding parameters suggest that detrusor contractility and efficiency decrease with age.

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.

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.

Are voiding symptoms really associated with abnormal urodynamic voiding parameters in women?

OBJECTIVES

To examine the relationship between voiding symptoms and objective measurements of voiding dysfunction.

METHODS

We prospectively collected data from 116 consecutive women attending for urodynamic investigations. Symptoms of voiding dysfunction and objective voiding parameters including uroflowmetry and post-void residual volume were evaluated.

RESULTS

Sixteen (14%) patients reported a symptom of straining, 21 (18%) double voiding, 32 (27%) post-micturition dribbling, 10 (8%) poor stream and 34 (29%) incomplete emptying. Using receiver-operator curves we were unable to determine a cut-off value for flow or residual volume where symptoms became more prevalent. Poor stream was, however, a good predictor for a residual volume of >100 mL and >150 mL. Strain predicted a residual volume of >100 and >150 mL and it correlated with maximum flow rate <15 mL/s. The other three symptoms did not correlate with any of the cut-off values.

CONCLUSIONS

Poor steam and strain are weakly predictive of abnormal voiding function.

Resolution of elevated postvoid residual volumes after correction of severe pelvic organ prolapse

We hypothesized that elevated postvoid residual volume (PVRV) would resolve postoperatively in women with severe pelvic organ prolapse (POP) and investigated risk factors that might hamper its resolution. Retrospectively, we enrolled 57 patients undergoing surgery for severe POP. All patients had preoperative PVRV > or = 100 ml documented by ultrasound and catheterization. Presurgical voiding difficulty, urodynamic and cystoscopic data, and surgical outcome were analyzed. The incidence of postsurgical elevated PVRV was 15.8% and 3.5% was symptomatic. Patients with postsurgical elevated PVRV had larger preoperative residual volume than those with normal postsurgical PVRV (P = 0.037). By multivariable analysis, concomitant anti-incontinence surgery was the single independent predictor of postsurgical elevated PVRV (odds ratio = 5.38, P = 0.031). A majority of patients with severe POP had their elevated PVRV resolved postoperatively. Although concomitant anti-incontinence surgery increased the risk of developing elevated PVRV after repair, most remained asymptomatic.

Immediate postvoid residual volumes in women with symptoms of pelvic floor dysfunction

OBJECTIVE

To estimate the prevalence and clinical and urodynamic associations of postvoid residual volumes (PVRs), measured immediately after micturition, in women with symptoms of pelvic floor dysfunction.

METHODS

The patients were 1,140 women presenting consecutively for their initial urogynecological assessment, including urodynamics. They were studied prospectively. Measurement of PVRs was by transvaginal ultrasonography within 60 seconds of micturition. After the estimation of prevalence of the different levels of PVR, an appropriate upper limit of normal PVR was estimated and associations then were sought for PVRs with a wide range of clinical and urodynamic parameters.

RESULTS

The overall prevalence of PVRs was 76% at 0-10 mL, 5% at 11-30 mL, 5% at 31-50 mL, 8% at 51-100 mL, and 6% at more than 100 mL. Thus, using transvaginal ultrasonography, 81% of immediate PVRs were 30 mL or less. Higher than 30 mL, a significantly increased prevalence of women presenting with recurrent urinary tract infections (UTIs) was noted (P<.001). The level of 30 mL was deemed to be an appropriate upper limit of normal PVR. The prevalence of PVRs higher than 30 mL increased significantly with age (P<.001) and higher grades of prolapse (P<.001). There was a significant inverse relation of PVRs higher than 30 mL to the symptom of stress incontinence (P=.018) and the diagnosis of urodynamic stress incontinence (P<.001).

CONCLUSION

Eighty-one percent of immediate PVRs (95% confidence interval 79-84%) in symptomatic women are 30 mL or less. Postvoid residual volumes higher than this level are significantly associated with increasing age, higher grades of prolapse, and an increased prevalence of recurrent UTIs.

LEVEL OF EVIDENCE

II.

[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.

Surgical and nonsurgical approaches to treat voiding dysfunction following antiincontinence surgery

PURPOSE OF REVIEW

To review conservative and operative approaches to treat voiding dysfunction after antiincontinence operation.

RECENT FINDINGS

Voiding dysfunction is a complication of antiincontinence surgery. Unfortunately, there are no consistent preoperative findings that can predict this morbidity. By design, antiincontinence surgery must create some degree of obstruction during the nonvoiding phase in order to be effective. When the continence operation overcorrects anatomy, however, de-novo irritative and/or obstructive symptoms may develop. The traditional pubovaginal sling is more likely to produce voiding dysfunction than is colposuspension or the midurethral sling. Fortunately, most voiding dysfunction is transient and resolves spontaneously in a few days to weeks. Clean intermittent self-catheterization is the mainstay of conservative management. When symptoms persist, either sling incision or urethrolysis may be performed. The simple incision involves cutting the sling in the midline, while formal urethrolysis entails dissection, entry into the retropubic space, and mobilization of the urethra from the pubic bone.

SUMMARY

Voiding dysfunction after antiincontinence surgery is usually transient, but if surgery is required because of a persistence of symptoms then simple sling incision and vaginal urethrolysis have a high success rate and recurrent stress urinary incontinence is infrequent.

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.

Effect of Childhood Dysfunctional Voiding on Urinary Incontinence in Adult Women

OBJECTIVE

To determine whether a history of childhood dysfunctional voiding is associated with urinary incontinence in adulthood.

METHODS

Using a case-control study, we surveyed patients presenting with or without urinary incontinence. Cases were patients referred to a tertiary urogynecology clinic, and controls were patients referred to a general gynecology clinic. Patients completed a validated childhood questionnaire about dysfunctional voiding. A total score of 6 or more in girls is indicative of dysfunctional voiding, a condition characterized by urgency, frequency, constipation, urinary or fecal incontinence, and/or urinary tract infections. Using an alpha of 0.05, a power of 80%, and a baseline prevalence of dysfunctional voiding of 8%, we determined that 170 patients were needed to show a 3-fold difference between groups.

RESULTS

Cases (n = 84) and controls (n = 86) had similar baseline characteristics except for body mass index and incidence of previous pelvic surgery. Although the total dysfunctional voiding score was higher in cases than controls (7.3 versus 5.0, respectively; P = .001), the difference in the number (%) of patients with history of childhood dysfunctional voiding between the 2 groups was not significant (47 [56%] versus 36 [42%], respectively; odds ratio 1.76, 95% confidence interval 0.96-3.24; P = .07). When all patients from both groups were combined, there was a higher prevalence of a history of childhood dysfunctional voiding in women with or without current urinary frequency (P = .004), urgency (P = .03), stress incontinence (P = .01), and urge incontinence (P = .009).

CONCLUSION

Women with adult lower urinary tract symptoms may have a higher prevalence of history of childhood dysfunctional voiding.

LEVEL OF EVIDENCE

II-2.

Evidence of occult dysautonomia in Fowler's syndrome: alteration of cardiovascular autonomic function tests in female patients presenting with urinary retention

OBJECTIVE

To assess the hypothesis that an occult impairment of the autonomic system might represent one of the mechanisms of urinary disturbance in Fowler's syndrome (FS), in which the pathophysiology of urinary retention is the predominant feature.

PATIENTS AND METHODS

We prospectively investigated 10 women (mean age 43.7 years) with FS, diagnosed by assessing both voiding-phase dysfunction (complete or incomplete retention with a residual urine volume of >150 mL, and a maximum flow rate of <15 mL/s), abnormalities of striated urethral sphincter electromyography (decelerating bursts and complex repetitive discharges), the presence of polycystic ovaries and absence of any apparent usual causes (obstructive, neurological diseases). The women had a urodynamic investigation, electromyographic examination, cystoscopy, brain and spinal cord magnetic resonance imaging (MRI) and cardiovascular autonomic function tests (CAFTs, i.e. heart rate variability to deep breathing, cold-pressor test, Valsalva ratio, blood pressure response to standing, and sympathetic skin responses), for parasympathetic and sympathetic functions. Evidence of dysautonomia, as classically described, was defined by two or more positive CAFTs.

RESULTS

The mean duration of symptoms was 7.9 years; there was urinary retention in six patients (one complete and five incomplete) and the other four complained of straining to void, diminished stream and hesitancy. Five patients were using intermittent self-catheterization. Six patients had two or more positive CAFTs and were considered to have dysautonomia. In all 10 women the clinical neurological and urological examinations were normal with no apparent clinical symptoms of dysautonomia (blurred vision, pupil abnormalities, clinical manifestations of postural hypotension, gastrointestinal symptoms). Brain and spinal cord MRI, cystoscopy, bladder and kidney ultrasonography, sacral-evoked latencies and cortical-evoked responses after pudendal nerve stimulation were normal.

CONCLUSION

There was an occult impairment of the autonomic system in women with FS; this condition might be a pure bladder expression of a generalized but occult dysautonomia, which in some cases might be diagnosed using CAFTs.

Female voiding dysfunction

Female voiding dysfunction is poorly understood; it lacks standard definitions, and there is no consensus on diagnostic criteria. In the majority of women who are neurologically intact the cause is idiopathic. It affects the sufferers' quality of life, but unfortunately there is a paucity of published literature on its management. This review examines the current knowledge on the management of this common problem. Diagnosis is aimed at identifying the underlying aetiological factors, which are discussed, as well as the importance of a detailed history and focused physical examination. Investigations essential to management are outlined. Developments in the medical treatment of voiding dysfunction have been disappointing. The role of surgery is even more limited except for those with postoperative voiding problems after new-generation sling procedures. Intermittent self-catheterisation, supervised and supported by a dedicated nursing specialist, remains the mainstay of management. A multidisciplinary approach is essential to success. Emerging treatment modalities such as sacral and peripheral neuromodulation and the use of alpha(1)-blockers are discussed. Botulinum toxin A injections have been useful in some cases. There are relatively few publications on the effectiveness of these interventions in clinical practice. These issues need to be addressed by quality research. Female voiding dysfunction presents a challenge to urogynaecologists and urologists alike.

Transurethral resection in women with lower urinary tract symptoms

BACKGROUND

To evaluate the preliminary safety, efficacy and complications of transurethral resection (TUR) in the management of women with lower urinary tract symptoms.

METHODS

One hundred and eight women (mean age, 57.6 years) with moderate to severe lower urinary tract symptoms underwent TUR between September 1998 and December 2002. At preoperative baseline, 6 months and 24 months postoperatively, all patients underwent clinical evaluations including the standardized American Urological Association symptom score, peak urine flow, postvoid residual urine volume and quality-of-life assessments. Operative time, catheter time, hospital stay and incidence of side-effects were also recorded.

RESULTS

The total mean operative time was 19.25 +/- 6.70 min. The mean catheter time was 26.2 +/- 12.8 h and the mean hospital stay was 2.08 +/- 0.84 days. No patient needed a blood transfusion or experienced hyponatremia. The total storage and voiding symptom scores and quality of life score had improved significantly 6 months after the surgical procedure (P < 0.01). There were little changes in peak flow rate and residual urine volume. Complications of the procedure included urinary tract infections (n = 4) and stress incontinence (n = 3). Two patients later underwent bladder neck suspension procedure.

CONCLUSIONS

In this preliminary study, there was significant clinical improvement maintained at all follow-up intervals and the results were not comparable to TUR of the prostate in men with clinical benign prostatic hyperplasia. The risks associated with TUR in women, especially of stress incontinence, are significant. A multicenter clinical trial is currently underway to determine the long-term efficacy and safety of TUR in women.

Residual Urine in an Elderly Female Population: Novel Implications for Oral Estrogen Replacement and Impact on Recurrent Urinary Tract Infection

PURPOSE

While the distribution of post-void residual urine volume (PVR) has been well studied in men, scant literature is available concerning PVR in women. We characterized any relationship between PVR and urinary tract infection (UTI). We also characterized other factors that could impact bladder emptying, including oral estrogen replacement therapy.

MATERIALS AND METHODS

Inclusion criteria were at least 2 clinic visits and no antimicrobial prophylaxis in the last year. Women with a history of diabetes or cystocele were excluded. In a 17-month period 204 women met inclusion criteria. PVR was measured by catheterized specimen. Patients were categorized into groups by UTI history, namely 94 of those with no UTIs in the last year (group 1) and 110 with 1 or more documented UTIs in the last year (group 2). Factors that could affect bladder emptying were tested for the impact on PVR.

RESULTS

Mean PVR in the study group was 53.13 ml. The mean PVR in groups 1 and 2 was 33 and 70.25 ml, respectively. The difference between these 2 groups was significant (p <0.0001). Estrogen status data were available on 186 patients. The 62 patients on estrogen replacement therapy had a mean PVR of 39.33 ml. The 124 patients not on estrogen replacement therapy had a mean PVR of 66.67 ml. The difference between these 2 groups was significant (p = 0.002) and independent of UTI history.

CONCLUSIONS

Of elderly women those with high PVR were more likely to have recurrent UTIs. Improved bladder function was documented in women receiving oral estrogen replacement therapy.

Uroflowmetry in female voiding disturbances

AIMS

The clinical validity of uroflowmetry in women is attenuated by lack of absolute normal values. A peak flow <15 mL/sec and/or residual urine >50 mL with a minimum total bladder volume of 150 mL before voiding (volume voided+residual) (method A) and the 10th centile curve of the Liverpool Nomogram (method B) for the maximum urine flow rate have been identified as useful discriminants when diagnosing voiding difficulties in women. This study compares the two methods and analyses the validity of uroflowmetry in female voiding disturbances.

METHODS

A total of 348 women underwent a full urogynaecologic work-up. Evaluable results of uroflowmetry (229 with method A and 224 with method B) were analysed and compared in terms of the following clinical variables: age, parity, previous urogynaecologic surgery, prolapse grade, symptoms, postvoid residue, and incontinence. Uroflowmetry results were compared with pressure/flow study results as indicated by four different cut-offs.

RESULTS

The odds ratio that a subject with voiding difficulty has abnormal flow is 3.7 (95% CI, 1.9-7) in the patients analysed with method A and 2.8 (95% CI, 1.6-5.2) with method B. A good accordance emerged between the two methods in flowmetry results. Uroflowmetry has a specificity of >70% and a sensitivity of 50 to 100% depending on the cut-offs. Uroflowmetry results in women can be analysed by using either of the methods.

CONCLUSIONS

Uroflowmetry has a good specificity, a high negative predictive value, and a good diagnostic capacity such as to make it useful as the first diagnostic approach in urogynaecologic patients.

Comparison of tension-free vaginal taping versus modified Burch colposuspension on urethral obstruction: a randomized controlled trial

AIMS

To determine whether the tension-free vaginal tape (TVT) procedure affects the mechanics of voiding in women with genuine stress incontinence (GSI).

METHODS

Between July of 1997 and July of 1999, 116 women with GSI in the absence of pelvic prolapse underwent a randomized controlled study of TVT vs. modified Burch colposuspension. The trial was conducted by using a standardized protocol, including strict criteria for excluding preexisting bladder outlet obstruction (BOO). Urodynamic studies including free flowmetry, filling (provocative) and voiding cystometry, and 1-hour pad test were performed before and at least 1 year after the operation. The Blaivas and Groutz nomogram was used as another criteria to assess the pre- and postoperative BOO.

RESULTS

Eighteen women were excluded from the study as a result of having preexisting BOO and an additional 8 were lost to follow-up. The comparison between pre- and postoperative variables for each procedure revealed that maximal flow rate of noninvasive uroflowmetry was significantly lower after operation in both groups (P = 0.009, P = 0.010, respectively). Detrusor pressure at maximal flow and urethral resistance were significantly higher and micturition volumes significantly lower after operation in the Burch group (P < 0.001, P < 0.001, P = 0.029, respectively). The difference between pre- and postoperative distribution of the obstruction nomogram of the Burch group was significantly different (P = 0.023).

CONCLUSIONS

Based on strict exclusion criteria for preoperative BOO, our findings strongly suggest that with a median 22 months (range, 12 to 36 months) of follow-up, a properly performed tension-free vaginal tape procedure does not cause urethral obstruction.

Study of the afferent nervous system and its evaluation in women with impaired detrusor contractility treated with bethanechol

OBJECTIVES

To study the effects of subcutaneous bethanechol on the afferent nervous system and correlate these with the efficiency of this treatment in women with impaired detrusor contractility and to evaluate whether patients likely to respond to bethanechol can be identified before treatment through sensation evaluation.

METHODS

Eighteen women with impaired detrusor contractility were given subcutaneous bethanechol for 10 days, and the flow pattern and postvoid residual urine volume were monitored. The afferent nervous system was studied before and after therapy by evaluating the sensation of filling during cystometry and by determining the bladder electrical perception threshold (EPT).

RESULTS

At the end of therapy, 61% voided without a postvoid residual volume. In these women, the sensation of filling and electrical sensitivity were significantly increased compared with before treatment. In women who still voided with a postvoid residual volume, the sensation of filling had increased to a lesser extent and no change in EPT was found. Women in whom bethanechol was unsuccessful had a higher pretreatment EPT than women who were successful. No such difference was found for the sensation of filling.

CONCLUSIONS

An increase in bladder sensitivity correlated with improvement in bladder emptying and can be evaluated by studying the sensation of filling and EPT. Patients likely to respond to bethanechol can be identified before treatment on the basis of the EPT level. Therefore, it would be valuable to initiate EPT measurement in the diagnosis of patients with impaired detrusor contractility.

Non-neurogenic female voiding dysfunction

PURPOSE OF REVIEW

The pathophysiological mechanisms of female voiding phase dysfunction are poorly understood, and there are neither standard definitions nor guidelines for diagnosis and treatment. The aim of this review is to present up-to-date data and controversies associated with non-neurogenic female voiding dysfunction.

RECENT FINDINGS

Conceptually, voiding phase dysfunction may have bladder or urethral causes. Bladder causes include detrusor contraction of inadequate magnitude or duration to effect bladder emptying (detrusor underactivity), or the absence of detrusor contraction (detrusor arreflexia). Urethral causes consist of bladder outlet obstruction as a result of urethral overactivity (functional obstruction), or anatomical (mechanical obstruction) pathologies. The specific prevalence and contribution of each of the above mechanisms is unknown. Furthermore, a correct and timely diagnosis may be difficult, because clinical features are very similar to those of other lower urinary tract symptoms, and diagnostic modalities are often inconclusive or even misleading. A full urodynamic evaluation is essential in making the diagnosis; however, standard urodynamic definitions are still lacking. In the following review, we will present recent findings associated with the prevalence, etiology and diagnosis of each of the different categories of female voiding phase dysfunction, and highlight new advances presented during the past year.

SUMMARY

Further epidemiological and pathophysiological investigations are needed to evaluate the causes and main risk factors of voiding dysfunction in women. A better understanding of the pathophysiological mechanisms associated with this challenging condition may provide the possibility to use appropriate diagnostic and treatment modalities, thus avoiding unnecessary interventions.

Why do women have voiding dysfunction and de novo detrusor instability after colposuspension?

OBJECTIVE

To investigate the causes of voiding dysfunction and new detrusor instability after colposuspension.

DESIGN

Prospective, observational study.

SETTING

Urogynaecology unit, district general hospital.

POPULATION

Seventy-seven women undergoing colposuspension for genuine stress incontinence.

METHODS

The following factors were investigated: 1. bladder neck elevation by magnetic resonance imaging before and after surgery; 2. urethral compression by measuring bladder neck approximation to the pubis with magnetic resonance imaging after surgery (anterior compression) and the distance between the medial stitches during surgery (lateral compression); 3. clinical and urodynamic factors.

MAIN OUTCOME MEASURES

1. Post-operative voiding function (i.e. first day of voiding and day of catheter removal); 2. objective evidence of detrusor instability three months post-operatively.

RESULTS

Pre-operative peak flow rate (P = 0.004), straining during voiding (P = 0.005), increasing age (P < 0.001), operative elevation (P < 0.001) and anterior urethral compression (P = 0.001) were associated with the number of days of post-operative catheterisation. Increasing age (P = 0.02), previous bladder neck surgery (P = 0.04), operative elevation (P = 0.049) and anterior urethral compression (P < 0.001) were associated with detrusor instability at three months.

CONCLUSION

Surgical factors (bladder neck elevation and compression) are associated with voiding dysfunction and detrusor instability after colposuspension. These findings have implications for prevention.

Voiding dysfunction

Voiding dysfunction in women is common, but is frequently undiagnosed until the patient presents with symptoms. The aetiology of voiding dysfunction includes the following, any of which may lead to acute or chronic disorders: obstructive causes; postsurgical conditions; neurological disorders; overdistension; inflammatory, pharmacological, psychogenic causes and learned voiding dysfunction; detrusor myopathy and urethral sphincter hypertrophy. Clinical assessment should include history, and general, neurological and pelvic examinations. Investigations may include uroflowmetry, ultrasound for residual urine and upper urinary tract dilatation, urodynamic assessment and electromyography. New surgical techniques to identify vesical branches of the pelvic nerves intraoperatively during radical hysterectomy have been shown to help prevent voiding dysfunction postoperatively. If acute retention occurs, then bladder drainage is the most important measure. Suprapubic catheters are superior to transurethral catheters if long-term voiding difficulties are expected. Whenever possible, patients with chronic retention should be taught clean intermittent self-catheterization. Depending on the cause, other possible treatment options include urethral dilatation, insertion of an intraurethral device, and neuromodulation. Voiding dysfunction in women is still poorly understood. Prompt management of acute retention is essential, and clean intermittent self-catheterization remains the most effective therapy for chronic retention.

Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology

The aim of our study was to construct a bladder outlet obstruction nomogram for women with lower urinary tract symptoms. A urodynamic database of 600 consecutive women was reviewed. Bladder outlet obstruction, utilizing strict diagnostic criteria, was diagnosed in 50 (8.3%) patients. A comparison of patient characteristics, uroflowmetry, and detrusor pressure-uroflow studies was carried out between the obstructed patients (mean age, 64.4 +/- 17.6 years) and 50 age-matched unobstructed controls (mean age, 64.8 +/- 10.7 years). Maximum flow rates were significantly higher in free uroflow studies (free Qmax) than in pressure-flow studies (Qmax), in both obstructed (9.3 +/- 3.7 versus 5.7 +/- 3.6 mL/s, respectively. P = 2. 6 10(-6)) and unobstructed (25.6 +/- 11.2 versus 11.8 +/- 5.9 mL/s, respectively. P = 8.7 10(-12)) patients. Comparison of detrusor pressure at maximum flow (pdet.Qmax) and maximum detrusor pressure during voiding (pdet.max) values did not reveal significant differences, in both obstructed (39.3 +/- 18.4 versus 49.7 +/- 25.5 cm H(2)O, respectively) and unobstructed (16.5 +/- 8.4 versus 20.6 +/- 9.2 cm H(2)O, respectively) patients. Further statistical analysis was carried out to construct bladder outlet obstruction nomogram. The nomogram classifies any pair of values of free Qmax and pdet.max into one of the following four zones: no obstruction, mild obstruction, moderate obstruction, and severe obstruction. Of the 50 obstructed women, 34 (68%) were classified by the nomogram as mildly, 12 (24%) as moderately, and 4 (8%) as severely obstructed. A positive correlation was found between subjective severity of the symptoms (assessed by the AUA Symptom Index score) and the four nomogram zones. In conclusion, the nomogram makes it possible to differentiate between obstructed and unobstructed women and between various degrees of obstruction. We believe the nomogram may also serve as an instrument to assess treatment outcomes.

Bladder outlet obstruction in women: definition and characteristics

The prevalence of bladder outlet obstruction in women is unknown and most probably has been underestimated. Moreover, there are no standard definitions for the diagnosis of bladder outlet obstruction in women. Our study was conducted to define as well as to examine the clinical and urodynamic characteristics of bladder outlet obstruction among women referred for evaluation of voiding symptoms. Bladder outlet obstruction was defined as a persistent, low, maximum "free" flow rate of <12 mL/s in repeated non-invasive uroflow studies, combined with high detrusor pressure at a maximum flow (p(det.Q)(max) >20 cm H(2)O) during detrusor pressure-uroflow studies. A urodynamic database of 587 consecutive women identified 38 (6.5%) women with bladder outlet obstruction. The mean age of the patients was 63.9 +/- 17.5 years. The mean maximum "free" flow, voided volume, and residual urinary volume were 9.4 +/-3.9 mL/s, 144. 9 +/- 72.7 mL, and 86.1 +/- 98.8 mL, respectively. The mean p(det. Q)(max) was 37.2 +/- 19.2 cm H(2)O. Previous anti-incontinence surgery and severe genital prolapse were the most common etiologies, accounting for half of the cases. Other, less common, etiologies included urethral stricture (13%), primary bladder neck obstruction (8%), learned voiding dysfunction (5%), and detrusor external sphincter dyssynergia (5%). Symptomatology was defined as mixed obstructive and irritative in 63% of the patients, isolated irritative in 29%, and isolated obstructive in other 8%. In conclusion, bladder outlet obstruction in women appears to be more common than was previously recognized, occurring in 6.5% of our patients. Micturition symptoms relevant to bladder outlet obstruction are non-specific, and a full urodynamic evaluation is essential in making the correct diagnosis and formulating a treatment plan.

Prevalence and characteristics of voiding difficulties in women: are subjective symptoms substantiated by objective urodynamic data?

OBJECTIVES

To examine the prevalence and characteristics of voiding difficulties in women.

METHODS

Two hundred six consecutive female patients who attended a urogynecology clinic were recruited. Patients were interviewed regarding the presence and severity of symptoms that would suggest voiding difficulties (ie, hesitancy, straining to void, weak or prolonged stream, intermittent stream, double voiding, incomplete emptying, reduction, and positional changes to start or complete voiding). Urodynamic evidence of voiding difficulty was considered as a peak flow rate less than 12 mL/s (voided volume greater than 100 mL), or residual urine volume greater than 150 mL, on two or more readings. Residual urinary volume, flow patterns, and pressure-flow parameters were analyzed and compared between symptomatic and asymptomatic patients who had urodynamic parameters of voiding difficulties.

RESULTS

One hundred twenty-seven (61.7%) women reported having voiding difficulty symptoms; 79 others (38.3%) were free of such symptoms. Urodynamic diagnosis of voiding difficulty was made in 40 women (19.4% of the study population): 27 in the symptomatic group and 13 in the asymptomatic group (21.2% and 16.5%, respectively). Only 1 patient had voiding difficulty due to bladder outlet obstruction. All other cases of low flow rate were due to impaired detrusor contractility.

CONCLUSIONS

Objective evidence of voiding difficulty may be found in both symptomatic and asymptomatic patients and is usually due to impaired detrusor contractility. The clinical significance of the abnormal flow parameters in asymptomatic patients is unclear.