A Survey on Voiding Complaints in Women Presenting at a Pelvic Care Center.

INTRODUCTION: This article reports the prevalence of self-reported voiding complaints and the relationship with other pelvic floor and bladder dysfunctions (PFD). MATERIALS AND METHODS: Women with a variety of PFDs were referred to the pelvic care center. A standardised questionnaire on 6 PFDs was used. Frequencies of patient characteristics, PFDs and voiding complaints were calculated. Cross tabulation was used to investigate correlations and Pearson correlation coefficients to reveal the strength of the association between PFDs and self-reported voiding complaints. RESULTS: Data of 4470 women were included. Prevalence of (self-reported) voiding Lower urinary tract symptoms was 59.5%. Incomplete bladder emptying is the most prevalent voiding complaint. Self-reported voiding complaints are weakly correlated to age (r = 0.15, p < 0.01) and have moderate correlation with self-reported recurrent urinary tract infections (r = 0.34, p < 0.01), pelvic floor, bladder and bowel complaints. However, the correlation between the feeling of incomplete bladder emptying and the presence of recurrent urinary tract infections is weak (r = 0.06, p = 0.02). CONCLUSION: Voiding complaints have a high prevalence and symptom bother in women visiting a pelvic care center.

The Value of Ambulatory Urodynamics in the Evaluation of Treatment Effect of Sacral Neuromodulation.

OBJECTIVES: To assess the improvement of symptoms by sacral neuromodulation (SNM) in an objective way by carrying out an ambulatory urodynamic study (ambulatory-UDS). Until now, successful treatment has been defined as a ≥50% improvement recorded on voiding diaries. Voiding diaries are a patient reported outcome tool. A tool with less bias is desired to evaluate the treatment results before an expensive permanent system is implanted. METHODS: Between 2002 and 2015, a total of 334 patients with lower urinary tract symptoms were included consecutively in an ambulatory-UDS database. From this database, a subgroup of patients was selected which underwent SNM. RESULTS: In 51 patients, an ambulatory-UDS was performed both at baseline and during the SNM test period. A positive treatment outcome after test stimulation based on the patients' voiding diary, correlated (p < 0.0001) with an improvement on ambulatory-UDS. Twenty-six of the 30 patients, who have showed improvement of more than 50% on voiding diary parameters and who had subjective improvement of their symptoms, showed an early improvement on ambulatory-UDS. CONCLUSIONS: Ambulatory-UDS can be used in clinical decision making, as it is associated with voiding diary improvement during the SNM test period. Using ambulatory-UDS to confirm success could in the future justify the shortening of the test period.

Transanal Endoscopic Microsurgery with or without Completion Total Mesorectal Excision for T2 and T3 Rectal Carcinoma.

AIM: Transanal endoscopic microsurgery (TEM) is used for the resection of large rectal adenomas and well or moderately differentiated T1 carcinomas. Due to difficulty in preoperative staging, final pathology may reveal a carcinoma not suitable for TEM. Although completion total mesorectal excision is considered standard of care in T2 or more invasive carcinomas, this completion surgery is not always performed. The purpose of this article is to evaluate the outcome of patients after TEM-only, when completion surgery would be indicated. METHODS: In this retrospective multicenter, observational cohort study, outcome after TEM-only (n = 41) and completion surgery (n = 40) following TEM for a pT2-3 rectal adenocarcinoma was compared. RESULTS: Median follow-up was 29 months for the TEM-only group and 31 months for the completion surgery group. Local recurrence rate was 35 and 11% for the TEM-only and completion surgery groups respectively. Distant metastasis occurred in 16% of the patients in both groups. The 3-year overall survival was 63% in the TEM-only group and 91% in the completion surgery group respectively. Three-year disease-specific survival was 91 versus 93% respectively. CONCLUSIONS: Although local recurrence after TEM-only for pT2-3 rectal cancer is worse compared to the recurrence that occurs after completion surgery, disease-specific survival is comparable between both groups. The lower unadjusted overall survival in the TEM-only group indicates that TEM-only may be a valid alternative in older and frail patients, especially when high morbidity of completion surgery is taken into consideration. Nevertheless, completion surgery should always be advised when curation is intended.

Can we define and characterize the aging lower urinary tract?-ICI-RS 2015.

The prevalence of lower urinary tract (LUT) symptoms increases with age but the etiology is unknown. This article aims to identify research directions that clarify the basis of this association. The initial question is whether biological age is the variable of interest or a time-dependent accumulation of factors that impact on LUT function at rates that differ between individuals. In particular, the accumulation of conditions or agents due to inflammatory states or tissue ischemia is important. Much of the above has been concerned with changes to bladder function and morphology. However, the outflow tract function is also affected, in particular changes to the function of external sphincter skeletal muscle and associated sacral motor nerve control. Nocturia is a cardinal symptom of LUT dysfunction and is more prevalent with aging. Urine production is determined by diurnal changes to the production of certain hormones as well as arterial blood pressure and such diurnal rhythms are blunted in subjects with nocturia, but the causal links remain to be elucidated. Changes to the central nervous control of LUT function with age are also increasingly recognized, whether in mid-brain/brainstem regions that directly affect LUT function or in higher centers that determine psycho-social and emotional factors impinging on the LUT. In particular, the linkage between increasing white matter hyperintensities and LUT dysfunction during aging is recognized but not understood. Overall, a more rational approach is being developed to link LUT dysfunction with factors that accumulate with age, however, the precise causal pathways remain to be characterized. Neurourol. Urodynam. 36:854-858, 2017. © 2017 Wiley Periodicals, Inc.

Ultrasound detrusor wall thickness measurement in combination with bladder capacity can safely detect detrusor underactivity in adult men.

PURPOSE: Detrusor underactivity (DU) has lately gained increasing interest because this bladder condition is an important cause of post-void residual urine and lower urinary tract symptoms (LUTS) in adult men. Until now, DU can only be diagnosed by pressure-flow measurement. Therefore, the aim of this study was to search for noninvasive tests which can safely predict DU in adult men. METHODS: Unselected, treatment-naïve male patients aged ≥40 years with uncomplicated, non-neurogenic LUTS were prospectively evaluated. All men received-after standard assessment of male LUTS-ultrasound detrusor wall thickness (DWT) measurements at a bladder filling ≥250 ml and computer urodynamic investigation. DU was defined as incomplete bladder emptying (>30 ml) in the absence of bladder outlet obstruction or dysfunctional voiding. Classification and regression tree (CART) analysis was used to determine parameters and threshold values for DU. RESULTS: The study population consisted of 143 consecutive men with medians of 62 years, IPSS 16, and prostate volume 35 ml. In total, 33 patients (23.1 %) had DU. CART analysis showed that all men with DWT ≤ 1.23 mm plus bladder capacity >445 ml had DU. This multivariate model has a sensitivity of 42 %, specificity of 100 %, positive predictive value of 100 %, and negative predictive value of 85 %. CONCLUSIONS: This study showed that all men with ultrasound DWT ≤ 1.23 mm + bladder capacity >445 ml have DU. Combination of these two tests could help physicians to diagnose DU noninvasively in clinical practice. A prospective independent study should confirm these results.

Detrusor underactivity in men with lower urinary tract symptoms/benign prostatic obstruction: characterization and potential impact on indications for surgical treatment of the prostate.

PURPOSE OF REVIEW: Detrusor underactivity is a highly prevalent type of voiding dysfunction in men and responsible for residual urine and decreased voiding efficiency. Patients with detrusor underactivity have an unfavorable outcome after prostatic surgery and do not have better long-term results than untreated detrusor underactivity patients. Therefore, differentiation between detrusor underactivity and bladder outlet obstruction (BOO) is crucial for the prediction of the outcome of prostatic surgery. RECENT FINDINGS: Patients with detrusor underactivity report more frequently about decreased/interrupted urinary flow, hesitancy, feeling of incomplete bladder emptying and/or decreased bladder sensation compared with men with normal pressure-flow studies. Determination of and differentiation between detrusor underactivity and BOO is only possible by pressure-flow studies. Threshold values for the diagnosis of detrusor underactivity have to be adjusted to the BOO-grade. A nomogram using BOO-index and maximum Watts factor is currently the most advanced tool to diagnose detrusor underactivity and/or BOO; values below the 25th percentile line indicate detrusor underactivity. It is desirable to establish tests to noninvasively diagnose detrusor underactivity. The combination of ultrasound detrusor wall thickness and bladder capacity can safely detect detrusor underactivity. SUMMARY: Careful assessment of voiding dysfunction to discriminate between detrusor underactivity and BOO should be done with pressure-flow studies, can avoid unsuccessful prostate surgery and helps in counselling patients.

Unravelling detrusor underactivity: Development of a bladder outlet resistance-Bladder contractility nomogram for adult male patients with lower urinary tract symptoms.

AIMS: Voiding dysfunction in adult men may be caused by bladder outlet obstruction (BOO) and/or detrusor underactivity (DU). Until now, it is only possible to classify BOO and DU by pressure-flow analysis. Low values of the maximum Watts factor (Wmax ) indicate DU but thresholds for the diagnosis have not been established. Purpose of this study was to construct a nomogram using bladder outlet resistance and detrusor contractility in order to classify BOO and DU simultaneously. METHODS: Treatment naïve men aged ≥40 years with uncomplicated lower urinary tract symptoms (LUTS) were prospectively evaluated. Patients were assessed with IPSS, prostate volume, uroflowmetry, post-void residual, and pressure-flow measurement. The bladder outlet obstruction index (BOOI) was used to determine BOO-grade and Wmax to calculate detrusor contractility. Individual BOOI-Wmax values were plotted in a graph. Linear interpolation was applied to determine the 10th, 25th, 50th, 75th, and 90th percentiles. RESULTS: Retrospective analysis of 822 male patients with means of 64 years, IPSS 16, and prostate volume of 40 cc. Patient and clinical parameters of the <25th percentile groups were significantly different compared to the 25th-50th percentiles: age (66 vs. 63 years, P = 0.006), bladder capacity (503 vs. 442 ml, P = 0.009), post-void residual urine (167 vs. 116 ml, P = 0.001), and voiding efficiency (67% vs. 73%, P = 0.015). CONCLUSIONS: The nomogram quantifies the relationship between detrusor contractility and BOO in men with LUTS. A measurement value <25th percentile correlates with clinical indicators of DU and is proposed as a cut-off value for DU-diagnosis. Higher age, bladder capacity, and PVR as well as lower voiding efficiency indicate DU. Neurourol. Urodynam. 35:980-986, 2016. © 2015 Wiley Periodicals, Inc.

Differentiation of lower urinary tract dysfunctions: The role of ambulatory urodynamic monitoring.

OBJECTIVES: To determine the value of ambulatory urodynamic monitoring in the assessment of patients with lower urinary tract symptoms. METHODS: This was a cross-sectional study including patients who underwent both conventional urodynamic and ambulatory urodynamic assessment at our Center between December 2002 and February 2013. The ambulatory urodynamic studies were interpreted in a standardized way by a resident experienced with urodynamic measurements, and one staff member who specialized in incontinence and urodynamics. RESULTS: A total of 239 patients (71 male and 168 female) were included in the present study. The largest subgroup of patients, 79 (33%), underwent ambulatory urodynamic monitoring based on suspicion of an acontractile bladder. However, 66 of these patients (83.5%) still showed contractions on ambulatory urodynamics. Other groups that were analyzed were patients with suspected storage dysfunction (47 patients), inconclusive conventional urodynamic studies (68 patients) and incontinence of unclear origin (45 patients). Particularly in this last group, ambulatory urodynamics appeared to be useful for discrimination between different causes of incontinence. CONCLUSIONS: Ambulatory urodynamic monitoring is a valuable discriminating diagnostic tool in patients with lower urinary tract symptoms who have already undergone conventional urodynamics, particularly in the case of patients with suspected bladder acontractility and incontinence of unclear origin during ambulatory urodynamics. Further study is required to determine the clinical implications of the findings and their relationship with treatment outcome.

Detrusor contraction power parameters (BCI and W max) rise with increasing bladder outlet obstruction grade in men with lower urinary tract symptoms: results from a urodynamic database analysis.

PURPOSE: To investigate to what extent detrusor work during voiding is influenced by bladder outlet obstruction (BOO) in adult men with lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: We reviewed data of patients with LUTS suggestive of benign prostatic hyperplasia who received computer-urodynamic investigations as part of their baseline clinical assessment. BOO was defined by the Schäfer classification and detrusor work during voiding was quantified by calculation of the bladder contractility index (BCI) and maximum Watt factor (W max) obtained by pressure-flow analysis. RESULTS: A total of 786 men with medians of 64 years, IPSS 16 and prostate volume of 35 ml, were included in the study. A total of 462 patients (58.8 %) had BOO (Schäfer 2-6). Both detrusor contraction power parameters continuously increased with rising BOO grade. Median BCI increased from 73.3 in Schäfer 0 to 188.0 in Schäfer 6, whereas W max increased from 9.6 to 23.4 W/m(2) (p < 0.001). Results of BCI and W max correlated well (p < 0.001). With increasing BOO grade, there was a significant decrease of voiding efficiency (p < 0.001). CONCLUSIONS: In adult male LUTS patients, detrusor contraction power parameters-BCI and W max-continuously increase with rising BOO grade. According to our results, it is impossible to determine a single threshold value for detrusor contraction power to diagnose detrusor underactivity in a group of LUTS patients with different BOO grades. The study is limited to men with non-neurogenic LUTS. Future studies should evaluate exact threshold values for BCI and W max in BOO subgroups to adequately define detrusor underactivity and investigate men with other bladder conditions.

Detrusor underactivity: Pathophysiological considerations, models and proposals for future research. ICI-RS 2013.

AIMS: Detrusor underactivity, resulting in either prolonged or inefficient voiding, is a common clinical problem for which treatment options are currently limited. The aim of this report is to summarize current understanding of the clinical observation and its underlying pathophysiological entities. METHODS: This report results from presentations and subsequent discussion at the International Consultation on Incontinence Research Society (ICI-RS) in Bristol, 2013. RESULTS AND CONCLUSIONS: The recommendations made by the ICI-RS panel include: Development of study tools based on a system's pathophysiological approach, correlation of in vitro and in vivo data in experimental animals and humans, and development of more comprehensive translational animal models. In addition, there is a need for longitudinal patient data to define risk groups and for the development of screening tools. In the near-future these recommendations should lead to a better understanding of detrusor underactivity and its pathophysiological background. Neurourol. Urodynam. 33:591-596, 2014. © 2014 Wiley Periodicals, Inc.