Postoperative urinary retention: risk factors, bladder filling rate and time to catheterization: an observational study as part of a randomized controlled trial.

BACKGROUND: Knowledge of risk factors for postoperative urinary retention may guide appropriate and timely urinary catheterization. We aimed to determine independent risk factors for postoperative urinary catheterization in general surgical patients. In addition, we calculated bladder filling rate and assessed the time to spontaneous voiding or catheterization. We used the patients previously determined individual maximum bladder capacity as threshold for urinary catheterization. METHODS: Risk factors for urinary catheterization were prospectively determined in 936 general surgical patients. Patients were at least 18 years of age and operated under general or spinal anesthesia without the need for an indwelling urinary catheter. Patients measured their maximum bladder capacity preoperatively at home, by voiding in a calibrated bowl after a strong urge that could no longer be ignored. Postoperatively, bladder volumes were assessed hourly with ultrasound. When patients reached their maximum bladder capacity and were unable to void, they were catheterized by the nursing staff. Bladder filling rate and time to catheterization were determined. RESULTS: Spinal anesthesia was the main independent modifiable risk factor for urinary catheterization (hyperbaric bupivacaine, relative risk 8.1, articaine RR 3.1). Unmodifiable risk factors were a maximum bladder capacity < 500 mL (RR 6.7), duration of surgery ≥ 60 min (RR 5.5), first scanned bladder volume at the Post Anesthesia Care Unit ≥250mL (RR 2.1), and age ≥ 60 years (RR 2.0). Urine production varied from 100 to 200 mL/h. Catheterization or spontaneous voiding took place approximately 4 h postoperatively. CONCLUSION: Spinal anesthesia, longer surgery time, and older age are the main risk factors for urinary retention catheterization. Awareness of these risk factors, regularly bladder volume scanning (at least every 3 h) and using the individual maximum bladder capacity as volume threshold for urinary catheterization may avoid unnecessary urinary catheterization and will prevent bladder overdistention with the attendant risk of lower urinary tract injury. TRIAL REGISTRATION: Dutch Central Committee for Human Studies registered trial database: NL 21058.099.07. Current Controlled Trials database: Preventing Bladder Catheterization after an Operation under General or Spinal Anesthesia by Using the Patient's Own Maximum Bladder Capacity as a Limit for Maximum Bladder Volume. ISRCTN97786497 . Registered 18 July 2011 -Retrospectively registered. The original study started 19 May 2008, and ended 30 April 2009, when the last patient was included.

[Good urodynamic practice: consensus on the terminology].

In this publication a summary of the published manuscript "Good Urodynamic Practices and Terms 2016: Urodynamics, uroflowmetry, cystometry, and pressure-flow study" developed by a working group under the guidance of the Standardization Steering Committee of International Continence Society (ICS)1 is presented. The members of the working group were: Werner Schaefer, Gunnar Lose, Howard B. Goldman, Michael Guralnick, Sharon Eustice, Tamara Dickinson, Hashim Hashim and Peter F.W.M Rosier.

[Guideline 'Delirium']. / Richtlijn 'Delirium'.

The Dutch Association of Psychiatry, together with the Dutch Association of Clinical Geriatrics and with methodological support from the Dutch Institute for Healthcare Improvement (CBO) has developed a guideline for the optimal diagnosis, treatment and prevention of delirium. Delirium is caused by somatic illness or the use of medication, drugs or alcohol. Delirium is common among the somatically ill admitted to a general hospital and is associated with increased morbidity and mortality. Important predisposing factors for delirium are: age > or =70 years, cognitive disturbances, sensory impairments, problems in daily activities, and the use of alcohol and opiates. Precipitating factors that may provoke delirium are: infection, fever, dehydration, serum electrolyte imbalance, polypharmacy, and the use of psychotropic medication, particularly anticholinergic drugs. Detection, diagnosis, and assessment of the severity of delirium are based on clinical examination, case history, observation, mental status examination including tests of cognitive function, and diagnosis of underlying somatic diseases. For daily practice, measurement tools are not necessary, nor are laboratory or imaging tests, such as electroencephalography. Haloperidol is the treatment of first choice for delirium due to somatic illness, except in patients with delirium due to drug use or medication, Parkinson's disease or Lewy body dementia. In cases of concurrent alcohol withdrawal syndrome, delirium may be treated with haloperidol and a benzodiazepine and B-vitamins. Medical and environmental interventions have been shown to reduce the incidence and duration of delirium.

Urodynamic and clinical effects of noninvasive and minimally invasive treatments in elderly men with lower urinary tract symptoms stratified according to the grade of obstruction.

OBJECTIVES: We investigated the symptomatic and urodynamic effects of several noninvasive and minimally invasive treatment modalities to quantify these effects and to compare subjective and objective results within groups with various degrees of obstruction. METHODS: In a prospective study at one center, 487 patients who completed a full screening program including urodynamic investigation started treatment with watchful waiting, terazosin, transurethral microwave thermotherapy, or laser treatment of the prostate; they were re-evaluated symptomatically and urodynamically after 6 months of therapy. The symptomatic and urodynamic results of 87 patients from another center who underwent transurethral resection of the prostate and who had their second urodynamic evaluation 6 months after surgery were also included. RESULTS: In patients without bladder outlet obstruction (BOO), improvement in maximum flow and symptom scores with little change in the degree of obstruction was most apparent, whereas a decrease of detrusor pressure at maximum flow was observed mainly in patients with BOO. The urodynamic effect but not the symptomatic effect of treatments depended on the initial grade of BOO. Urodynamic changes were more marked in the minimally invasive treatment groups compared with the noninvasive treatment groups. CONCLUSIONS: In symptomatic patients with benign prostatic hyperplasia, symptomatic improvement in the short term does not seem to depend on changes in urodynamic parameters. Future well-controlled studies focusing on the durability of symptomatic and urodynamic effects will be needed to illustrate the relative potential of urodynamic and other clinical parameters to predict a favorable response to current and innovative treatments.

Urodynamic and clinical effects of terazosin therapy in symptomatic patients with and without bladder outlet obstruction: a stratified analysis.

OBJECTIVES: To evaluate clinical and urodynamic changes in patients with and without bladder outlet obstruction (BOO) and to compare the clinical and urodynamic results of terazosin treatment between patients with and without BOO. METHODS: In a prospective study, 97 patients who completed a full screening program including urodynamic investigation with pressure-flow study analysis started treatment with terazosin. A total of 60 patients completed 6 months of treatment and were re-evaluated with International Prostate Symptom Scores (IPSS), uroflowmetry, and urodynamic investigation with pressure-flow study analysis. Patients were stratified using the linear passive urethral resistance relation (lin-PURR) classification according to Schäfer. Patients with a lin-PURR of 3 or more were classified as patients with BOO and patients with a lin-PURR of 2 or less were classified as patients without BOO. The clinical and urodynamic changes within and between the groups with and without BOO were evaluated. RESULTS: Terazosin resulted in significant symptomatic relief (9 points on the IPSS scale; P < 0.01) and a significant improvement of free urinary flow (3.0 mL/s; P < 0.01). In patients with BOO, a statistically significant improvement of all urodynamic obstruction variables (P < 0.01) was shown. In patients without BOO, a significant improvement of free urinary flow (4.4 mL/s; P < 0.01), a statistically significantly improved bladder capacity (increase of 70 mL; P = 0.01), and no statistically significant changes in urodynamic obstruction variables (P > 0.05) were shown. Patients with a hypoactive detrusor were more prone to early dropout. When comparing the changes of symptoms (P = 0.89), quality of life (P = 0.85), and the number of patients with improvements of free uroflow of at least 30% (P = 0.15), there appeared to be no significant difference between the groups with and without BOO. CONCLUSIONS: Although there is a statistically significant difference in urodynamic response to terazosin treatment between patients with and without BOO, we cannot recommend the use of pressure-flow studies in the selection of patients for terazosin treatment because the clinical results of treatment appear not to be significantly different between patients with and without BOO. It seems more useful, and certainly less expensive and less invasive, to start alpha 1-blocker therapy if, on clinical grounds, the urologist considers the patient to be a candidate for alpha 1-blocker therapy, and to continue therapy in those who respond.

The correlation between bladder outlet obstruction and lower urinary tract symptoms as measured by the international prostate symptom score.

PURPOSE: We studied the relationship between lower urinary tract symptoms as measured by the international prostate symptom score (I-PSS) and urodynamic findings in elderly men. MATERIALS AND METHODS: We evaluated 803 consecutive patients with lower urinary tract symptoms via the I-PSS and urodynamics with pressure-flow studies. RESULTS: A statistically significant correlation was found between all I-PSS questions (except intermittency) and objective parameters of obstruction. However, the clinical significance of this finding is minimal because a large overlap of symptom scores exists among patients with different grades of bladder outlet obstruction. The filling component of the I-PSS correlated somewhat better with obstruction than did the voiding component. CONCLUSIONS: It seems impossible to diagnosis bladder outlet obstruction from symptoms alone. It does not even seem possible to define subgroups in which further urodynamic examination is indicated.

Variability of clinical and pressure-flow study variables after 6 months of watchful waiting in patients with lower urinary tract symptoms and benign prostatic enlargement.

PURPOSE: We quantified the physiological variability of clinical and pressure-flow study variables in patients with symptomatic benign prostatic enlargement. MATERIALS AND METHODS: Symptom scores were measured, and advanced urodynamic studies with pressure-flow analysis were performed in 178 patients before and 6 months after a period a watchful waiting. RESULTS: Patients without bladder outlet obstruction experienced significant symptomatic improvement. Symptoms in patients with obvious bladder outlet obstruction did not improve significantly. The reproducibility of mean pressure-flow variables was evident. However, there was an important intra-individual variability. Patients with obvious bladder outlet obstruction showed a significant decreases in detrusor pressure at maximal flow of 14cm. water, a significant decrease in the urethral resistance factor of 7 cm. water and a significant decrease of 1 obstruction class on the linear passive urethral resistance relation nomogram, indicating less severe bladder outlet obstruction. CONCLUSIONS: Mean differences among therapy groups must be regarded critically, especially when the difference are slight and possibly within physiological variability.

Evaluation of detrusor activity during micturition in patients with benign prostatic enlargement with a clinical nomogram.

PURPOSE: We investigated the accuracy of analysis of detrusor contraction during micturition with a simple to use pressure-flow nomogram (linear passive urethral resistance relation). The computer derived maximum detrusor contraction parameter was used as a reference. The correlation with bladder emptying capability was used as a control. MATERIALS AND METHODS: Advanced pressure-flow analysis was performed in 224 elderly men with lower urinary tract symptoms. RESULTS: All patients with a contraction classified as normal on the nomogram had good maximum detrusor contractions. However, 50% of the patients with a weak classification on the nomogram showed good maximum detrusor contractions. CONCLUSIONS: The nomogram is useful in the selection of patients with a good detrusor contraction.

Clinical diagnosis of bladder outlet obstruction in patients with benign prostatic enlargement and lower urinary tract symptoms: development and urodynamic validation of a clinical prostate score for the objective diagnosis of bladder outlet obstruction.

PURPOSE: We attempted to improve the method of objective clinical evaluation of patients with benign prostatic enlargement and lower urinary tract symptoms. MATERIALS AND METHODS: We compared the results of free uroflowmetry and transrectal ultrasound prostate size determination with those of pressure-flow analysis of bladder outlet obstruction in 871 consecutive elderly men. RESULTS: Maximal flow, prostate size, and post-void residual and voided volumes were correlated with bladder outlet obstruction to derive a clinical prostate score. CONCLUSIONS: Clinical prostate score shows a superior correlation with bladder outlet obstruction than isolated objective parameters or symptom scores.

The correlation between urodynamic and cystoscopic findings in elderly men with voiding complaints.

PURPOSE: We evaluated the urethrocystoscopic findings and results of urodynamic studies in elderly men with voiding complaints. MATERIALS AND METHODS: A total of 492 consecutive patients with voiding complaints underwent a standardized screening program, including transrectal ultrasonography of the prostate, urodynamic investigations with pressure-flow study analysis and flexible urethrocystoscopy. RESULTS: A significant correlation was found between bladder trabeculation and grade of bladder outlet obstruction. Detrusor instability correlated significantly with grade of trabeculation. Grade of obstruction showed a clear correlation with prostatic occlusion of the urethra and the presence of a middle lobe at cystoscopy. CONCLUSIONS: The findings at urethrocystoscopy correlate well with those of urodynamic investigations.

Comparison of passive urethral resistance relation and urethral resistance factor in analysis of bladder outlet obstruction in patients with benign prostatic enlargement.

Analysis of the pressure/flow relation renders objective and detailed information on bladder outlet obstruction. The benefit of pressure/flow analysis for clinical and fundamental research questions, however, cannot be acknowledged without comparison of the different methods that exist. We compared one parameter analysis (URA) with two parameter (PURR) analysis in 99 consecutive patients with benign prostatic enlargement. The normal (instantaneous intrapatient) variability of both the PURR parameter Pvoidmin (minimal pressure during voiding) and the URA is approximately 10-15 cm H2O. Within these limits agreement between the two methods of analysis in the quantification of (minimal) outlet obstruction was observed in about 50% of the cases. However, when Qmax is less than 6 ml/s (in 49.5% of the patients) the URA number exceeds the value Pvoidmin in 96% of the cases. Predominantly this is caused by the fact that in the majority of these cases the type of bladder outlet obstruction is more constrictive than the URA curve, based on Pdet at Qmax indicated. In patients with a low flow rate and/or a constrictive type of obstruction, the Pvoidmin resulting from PURR analysis indicates a lower minimal pressure during voiding compared to URA.

Analysis of maximum detrusor contraction power in relation to bladder emptying in patients with lower urinary tract symptoms and benign prostatic enlargement.

PURPOSE: We evaluate the relationship among post-voiding residual urine volume, bladder outlet obstruction and maximum detrusor contractility power. MATERIALS AND METHODS: We investigated urodynamically and retrospectively 242 elderly men with various grades of bladder outlet obstruction and symptoms. RESULTS: Residual urine predominantly correlated with bladder outlet obstruction and not with maximum detrusor contractility power. Maximum detrusor contractility power showed significant positive correlation with bladder outlet obstruction. Urodynamically, the detrusor compensates for bladder outlet obstruction with elevated maximum detrusor contractility power. Decay of contraction during micturition however, hampers effective emptying. CONCLUSIONS: Maximum detrusor contractility power limits for normal detrusor contractility must be related to bladder outlet obstruction grade. Based on the results of our analysis, new limits showing improved correlation with complete emptying were derived.

Urodynamic assessment in the laser treatment of benign prostatic enlargement.

OBJECTIVE: To determine if bladder outlet obstruction can be adequately relieved after laser prostatectomy. PATIENTS AND METHODS: Since November 1992, a total of 105 patients underwent laser treatment of the prostate because of complaints related to benign prostatic enlargement (BPE). To date, urodynamic data from a study of pressure flow analysis are available for 79 patients both at baseline and at 6 months after treatment. Patients were evaluated using changes in symptoms (IPSS symptom score), peak flow rate (Qmax), post-voiding residual volume (PVR), detrusor pressure at maximum flow (Pdet at Qmax), and the linear passive urethral resistance relation (LPURR). Moreover, patients with minimal bladder outlet obstruction were compared to patients with severe bladder outlet obstruction. RESULTS: There was a significant improvement in mean IPSS score from 21.3 at baseline to 5.3 at the 6-month follow-up. The Qmax improved from 7.9 mL/s to 17.8 mL/s, and the PVR decreased from 91.6 mL to 15.6 mL. At baseline, > 80% of the patients were considered obstructed according to the analysis of pressure flow, whereas 6 months after laser treatment, only 5% of the patients were still considered obstructed. A comparison of the outcome between minimally obstructed patients and severely obstructed patients showed comparable improvements. CONCLUSION: Laser therapy of the prostate was, according to urodynamic parameters, capable of relieving outlet obstruction and minimally obstructed patients also showed a significant relief of outlet obstruction.

Urodynamic results of laser treatment in patients with benign prostatic hyperplasia. Can outlet obstruction be relieved?

PURPOSE: A urodynamic study was done to judge the capability of laser treatment to relieve bladder outlet obstruction. MATERIALS AND METHODS: Advanced urodynamic studies with pressure-flow analysis were performed before and 6 months after laser treatment using 3 different laser devices. RESULTS: Forty patients showed significant improvement in all obstruction parameters (detrusor pressure at maximum flow rate, urethral resistance relation, theoretical cross-sectional urethral area, minimal detrusor pressure and linear passive urethral resistance relation) together with significant subjective improvement in international prostate symptom score. After treatment 82 to 92% of the patients could no longer be considered to have obstruction. No difference in outcome among the devices used was found. CONCLUSIONS: Laser prostatectomy is indeed capable of relieving bladder outlet obstruction.

Variability of pressure-flow analysis parameters in repeated cystometry in patients with benign prostatic hyperplasia.

Urodynamic investigation becomes increasingly important in the diagnosis of bladder outflow obstruction in patients with benign prostatic hyperplasia. To date, different methods for evaluation of the pressure-flow relationship and quantification of the grade of obstruction are available. Models for pressure-flow analysis are briefly explained. The variability of the parameters is investigated by evaluation of 75 patients in whom 2 sequential voidings during urodynamic investigation were analyzed. The results showed that in 87% of these patients individual maximum flow differences of first and second voidings were less than 2 ml. per second. Individual detrusor pressure at maximum flow differences were less than 15 cm. water in 80% of these patients, while in 80% the intra-individual variation of the pressure-flow results was less than 15 cm. water for the minimal voiding pressure parameters (minimal urethral opening detrusor pressure and urethral resistance factor). For the pressure-flow parameter that defines the theoretical urethral lumen during voiding, the variation was less than 1.5 mm.2 in 84% of the patients. Patients with larger intra-individual differences are discussed. We concluded that the observed, aforementioned differences can be regarded as an indication of normal intra-individual variability of voiding during urodynamic investigation. This intra-individual variability, however, seldom leads to a change in the clinical grade of bladder outflow obstruction. We conclude that investigators involved in therapeutic trials of benign prostatic hyperplasia must be aware of this intra-individual variability of micturition, since this variability is greater than the refined scale of the pressure-flow analysis models.

Is detrusor instability in elderly males related to the grade of obstruction?

Analysis of 185 consecutive patients with BPH revealed concomitant detrusor instability in 20% of the patients. Of all patients 30.9% were not obstructed, 51.8% were moderately obstructed and 17.3% were severely obstructed. Patients with detrusor instability during filling cystometry revealed no differences in average age, prostate volume or symptoms. Mean filling cystometry parameters revealed earlier sense of urge correlating with higher pressures at lower volumes in patients with detrusor instability. Pressure-flow analysis showed no differences between the patients with and without detrusor instability in bladder outflow obstruction parameters. Further analysis, however, revealed that the prevalence of patients with detrusor instability reaches a "steady state" at a moderate level of obstruction. On clinical epidemiological grounds, the conclusion is made that detrusor instability is developing in the early phase of obstruction. Probably detrusor instability and bladder outflow obstruction are concomitant, due to the aging process in many of these patients.