Identifying occult bladder outlet obstruction in women with detrusor-underactivity-like urodynamic profiles.

Voiding dysfunction can result from detrusor underactivity (DU), bladder outlet obstruction (BOO), or both. Conceptually, women with high-pressure low-flow urodynamic profiles are diagnosed with BOO without DU. However, the possibility of BOO is often neglected in women with DU-like (low-pressure low-flow) urodynamic (UDS) profiles. By reviewing the videourodynamic studies (VUDS) of 1678 women, our study identified the key factors suggesting urodynamic BOO (determined by radiographic evidence of obstruction) in women with DU-like UDS profiles (Pdet.Qmax < 20 cmH2O and Qmax < 15 mL/s). In 355 women with DU-like UDS profiles, there were 70 (19.7%) with BOO and 285 (80.3%) without BOO. The BOO group had predominantly obstructive symptoms. The BOO group showed significantly decreased bladder sensation, lower detrusor pressure (Pdet.Qmax), lower flow rate (Qmax), smaller voided volume, and larger post-voiding residual (PVR) compared to the non-BOO group. In multivariate analysis, volume at first sensation, Qmax, PVR, and detrusor overactivity (DO) remained independent factors for BOO. The receiver operating characteristic (ROC) areas for the parameters were largest for PVR (area = 0.786) and Qmax (area = 0.742). The best cut-off points were 220 mL for PVR and 4 mL/s for Qmax. Our findings provide simple indicators for BOO in women with DU.

Patients with renal transplant and moderate-to-severe LUTS benefit from urodynamic evaluation and early transurethral resection of the prostate.

PURPOSE: To assess long-term renal function and micturition pattern of males submitted to transurethral resection of the prostate (TURP) for moderate-to-severe lower urinary tract symptoms (LUTS) after renal transplantation (RT). To investigate the role of clinical and urodynamic (UD) parameters for bladder outlet obstruction (BOO) diagnosis in these patients. METHODS: Retrospective data analysis of ≥ 50 years old patients who underwent RT between 01/2005 and 12/2016. Patients with moderate-to-severe LUTS after RT who underwent a urologic evaluation and a UD study were included. TURP was performed in case of BOO diagnosis. Kidney function and micturition patterns were evaluated before, 3, 12, 24, 36, and 48 months after TURP. Predictors of BOO were assessed at univariable and multivariable logistic regression models. Statistical analysis was performed with STATA16. RESULTS: 233 male patients ≥ 50 years underwent RT. 71/233 (30%) patients developed voiding LUTS. 52/71 (73%) patients with moderate-to-severe LUTS underwent UD. TURP was performed in 36/52 (69%) patients, with BOO diagnosis. Median (interquartile range) follow-up was 108 (75-136) months. Maximum flow at flowmetry (Qmax), International Prostate Symptom Score and post-voided residual volume improved significantly after surgery. Serum creatinine decreased and glomerular filtration rate improved significantly at follow-up, especially when TURP was performed ≤ 6 months from RT. At the multivariable model, bladder capacity ≥ 300 mL (OR = 1.74, CI 95% 1.03-3.15, p = 0.043) and detrusor pressure at Qmax (OR = 2.05, CI 95% 1.48-3.02, p = 0.035) were the independent predictors of BOO. CONCLUSION: RT patients with moderate-to-severe LUTS at risk for BOO and graft failure are better identified by UD than clinical parameters. Bladder capacity and voiding pressure are key for the early diagnosis of BOO.

BOO induces fibrosis and EMT in urothelial cells which can be recapitulated in vitro through elevated storage and voiding pressure cycles.

PURPOSE: To determine the unique contributions from elevated voiding and storage pressures in the development of fibrosis and the epithelial-to-mesenchymal transition (EMT) in urothelial cells, and how progressive BOO pressure cycling is an important mechanical cue leading to these pathological changes. MATERIALS AND METHODS: Urothelial cells isolated from control, SHAM, 2 (acute)- or 6 (chronic)-week BOO rats treated with an inflammasome inhibitor or no drug. Total RNA was isolated and RT-PCR was conducted with custom primers for pro-fibrotic and EMT genes. In separate experiments, a rat urothelial cell line was exposed to cyclic pressure regimes characteristic of acute and chronic BOO in the presence or absence of an inflammasome inhibitor. Following exposure, RT-PCR was conducted, collagen content was determined and intracellular caspase-1 activity was measured. RESULTS: Urothelial cells isolated from acute and chronic BOO rat models demonstrated expression of pro-fibrotic and EMT genes. Similarly, MYP3 rat urothelial cells subjected to pressure cycling regimes that reflect intravesical pressures in the acute or chronic BOO bladder also demonstrated increased expression of pro-fibrotic and EMT genes, along with elevated soluble collagen. Treatment with inflammasome inhibitors reduced expression of pro-fibrotic genes in the rat model and pressure cycling model but had a limited effect on EMT. CONCLUSION: These results indicate that acute and chronic BOO pressure cycling are essential in the initiation and progression of fibrosis in the bladder via the NLRP3 inflammasome, but also provide new evidence that there is also an alternative NLRP3-independent pathway leading to EMT and fibrosis.

Post-void residual urine ratio: A novel clinical approach to the post-void residual urine in the assessment of males with lower urinary tract symptoms.

PURPOSE: To assess the correlation between post-void residual urine ratio (PVR-R) and pathological bladder emptying diagnosed by pressure-flow studies (PFS) in males with lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: PVR-R and PVR urine were evaluated in 410 males underwent PFS for LUTS. PVR-R was the percentage of PVR to bladder volume (voided volume+PVR). Schafer and International Continence Society (ICS) nomograms, Bladder Contractility Index (BCI) were used to diagnose bladder outlet obstruction (BOO) and detrusor underactivity (DUA). We subdivided the cohort in 4 groups: Group I, BOO+/DUA+; Group II, BOO-/DUA+; Group III, BOO+/DUA-; Group IV, BOO-/DUA- (control group). We subdivided the 4 groups according to PVR-R strata: (1) 0%-20%; (2) 21%-40%; (3) 41%-60%; (4) 61%-80%; (5) 81%-100%. RESULTS: Group I had a greater median PVR-R (50%) with a >40% in 61.4% of the cohort. Median PVR-R was 16.6% in Group II, 24% in Group III, and 0% in the control Group. According to ICS nomograms and BCI, median PVR-R and PVR were significantly higher (p<0.001) in obstructed and underactive males. PVR-R threshold of 20% allowed to recognize males with voiding disorders with high sensibility, specificity, PPV, and NPV. A PVR-R cut-off of 40% identified males with associated BOO and DUA and more severe voiding dysfunction. CONCLUSIONS: A higher PVR-R is related to a more severe pathological bladder emptying, and to the association of BOO and DUA. PVR-R may have a clinical role in first assessment of males with LUTS and severe voiding dysfunction.

Cluster analysis of men undergoing surgery for BPH/LUTS reveals prominent roles of both bladder outlet obstruction and diminished bladder contractility.

Lower urinary tract symptoms (LUTS) in aging men are commonly attributed to bladder outlet obstruction from benign prostatic hyperplasia (BPH) but BPH/LUTS often reflects a confluence of many factors. We performed a hierarchical cluster analysis using four objective patient characteristics (age, HTN, DM, and BMI), and five pre-operative urodynamic variables (volume at first uninhibited detrusor contraction, number of uninhibited contractions, Bladder Outlet Obstruction Index (BOOI), Bladder Contractility Index (BCI) and Bladder Power at Qmax) to identify meaningful subgroups within a cohort of 94 men undergoing surgery for BPH/LUTS. Two meaningful subgroups (clusters) were identified. Significant differences between the two clusters included Prostate Volume (95 vs 53 cc; p-value = 0.001), BOOI (mean 70 vs 49; p-value = 0.001), BCI (mean 129 vs 83; p-value <0.001), Power (689 vs 236; p-value <0.001), Qmax (8.3 vs 4.9 cc/sec; p-value <0.001) and post-void residual (106 vs 250 cc; p-value = 0.001). One cluster is distinguished by larger prostate volume, greater outlet resistance and better bladder contractility. The other is distinguished by smaller prostate volume, lower outlet resistance and worse bladder contractility. Remarkably, the second cluster exhibited greater impairment of urine flow and bladder emptying. Surgery improved flow and emptying for patients in both clusters. These findings reveal important roles for both outlet obstruction and diminished detrusor function in development of diminished urine flow and impaired bladder emptying in patients with BPH/LUTS.

Metformin ameliorates bladder dysfunction in a rat model of partial bladder outlet obstruction.

Alteration of bladder morphology and function was the most important consequence of bladder outlet obstruction (BOO). Using a rat model of partial BOO (pBOO), we found that rats treated with metformin showed lower baseline pressures with a reduced inflammatory reaction in the early phase (2 wk) after pBOO. The NLR family pyrin domain containing 3 inflammasome pathway was inhibited in pBOO rat bladders with treatment of metformin in the early phase. Metformin reduced the activity of NLR family pyrin domain containing 3 in primary urothelial cells. In the chronic phase (9 wk after pBOO), metformin treatment ameliorated bladder fibrosis and improved the reduced compliance. Treatment with metformin suppressed the activation of Smad3 and compensated the diminished autophagy in 9-wk pBOO rat bladders. Autophagy was inhibited with upregulation of profibrotic proteins in primary fibroblasts from chronic pBOO bladders, which could be restored by administration of metformin. The antifibrotic effects of metformin on fibroblasts were diminished after silencing of AMP-activated protein kinase or light chain 3B. In summary, this study elucidates that oral administration of metformin relieves inflammation in the bladder during the early phase of pBOO. Long-term oral administration of metformin can prevent functional and histological changes in the pBOO rat bladder. The current study suggests that metformin might be used to prevent the development of bladder dysfunction secondary to BOO.NEW & NOTEWORTHY The present study in a rat model showed that oral administration of metformin alleviated inflammation following partial bladder outlet obstruction in the early phase and ameliorated bladder fibrosis as well as bladder dysfunction by long-term treatment. Our study indicated that metformin is a potential drug to inhibit bladder remodeling and alleviate bladder dysfunction. Clinical trials are needed to validate the effect of metformin on the bladder dysfunction and bladder fibrosis in the future.

Evaluation of neurogenic bladder outlet obstruction mimicking sphincter bradykinesia in male patients with Parkinson's disease.

BACKGROUND: Lower urinary tract symptoms are one of the most common groups of non-movement symptoms in patients with Parkinson's disease (PD). Storage symptoms are well-acknowledged, but neurogenic voiding dysfunction caused by PD remains a knowledge gap. This study aimed to evaluate the neurogenic bladder outlet obstruction in male patients with PD and its clinical significance. METHODS: Male patients who were diagnosed with PD and underwent urodynamic studies were retrospectively reviewed. The patients with prostate size < 30 ml and bladder outlet obstruction index ≥40 were included in the study. Lower urinary tract symptoms were evaluated by International Prostate Symptom Score (IPSS). Free flowmetry was performed and post void residual (PVR) volume was measured by ultrasound at follow-up. RESULTS: Six patients were included in the final analysis. The mean age was 68.2 and the mean movement symptom duration was 70.7 months. The patients had a mean IPSS of 12.5 and mean PVR volume of 70.8 ml. All patients had slow stream but none of them reported significant voiding difficulty. Urodynamic studies showed the delayed urinary sphincter relaxation and the special trace pattern. After a mean follow-up of 20 months, they had a mean IPSS of 12.5 and mean PVR volume of 73.3 ml. None of them complained of significant voiding difficulty at follow-up. CONCLUSION: The delayed urinary sphincter relaxation is a rare but repeatable phenomenon in male patients with PD. It is unlikely to cause disturbing voiding dysfunction, as reported by the patients, and does not progress prominently during the course of PD. Further studies are needed to investigate the nature of this special type of neurogenic BOO and whether it is peculiar to PD in a larger patient cohort.

Severe urinary tract damage secondary to primary bladder neck obstruction in women.

OBJECTIVE: To present the clinical and radiological characteristics of women with severe structural deterioration of the bladder and upper urinary tract secondary to Primary Bladder Neck Obstruction (PBNO), and their outcomes after bladder neck incision (BNI). METHODS: Retrospective evaluation of adult women who underwent BNI for PBNO at one institution. Patients were assessed for symptoms, renal function, structural abnormalities of the urinary tract and video-urodynamics. PBNO diagnosis was confirmed with video-urodynamics in all patients. BNI was performed at the 4-5 and/or 7-8 o'clock positions. Postoperative symptoms, PVR, uroflowmetry and renal function were evaluated and compared to baseline. RESULTS: Median patient age was 56.5 years (range 40-80). All presented with urinary retention-four were on clean intermittent Catheterization (CIC) and two with a Foley catheter. All patients had bladder wall thickening and diverticula. Four women had elevated creatinine levels, bilateral hydronephrosis was present in five (83.3%). After BNI, all patients resumed spontaneous voiding without the need for CIC. Median Qmax significantly improved from 2.0 [1.0-4.0] mL/s to 15 [10-22.7] mL/s (p = 0.031). Median PVR decreased from 150 to 46 [22-76] mL (p = 0.031). There were no postoperative complications. Creatinine levels returned to normal in 3/4 (75%) patients. CONCLUSION: PBNO in women may result in severe damage to the bladder and upper urinary tract. Despite severe structural abnormalities of the bladder, BNI was effective in reducing symptoms and improving structural and functional abnormalities of the lower and upper urinary tract.

The Postural Tachycardia Syndrome (PoTS) Bladder-Urodynamic Findings.

OBJECTIVE: To evaluate the urodynamics (UDS) of patients with postural tachycardia syndrome (PoTS). METHODS: Patients with a confirmed diagnosis of PoTS referred by the department of neuro-cardiology to the neuro-urology were identified and their UDS were retrospectively reviewed. RESULTS: In total, 50 patients (47 = 94.0% female) with confirmed PoTS and available UDS were identified. Mean age of females and males was 32.4 and 28.2 years, P = .15. Intermittent self-catheterisation was being used by 15/47 (31.9%) females at assessment. Detrusor overactivity was observed in 6 females (12.8%) (all at end fill and associated with urgency). In total, 14 (29.8%) females had no sensation of filling. No patients had an "unsafe" bladder. In total, 15/47 (31.9%) of women were unable to void with UDS catheters. Straining was reported in 22/35 (68.8%) of females. The female bladder outflow obstruction index = PDetQmax - 2.2(Qmax) was over 5 in 10/28 (35.7%) and over 18 in 5 (17.9%). The bladder contractility index = PDetQmax + 5Qmax was under 100 in 18/28 (28.6%) women. CONCLUSION: The UDS of patients with "PoTS bladder" often demonstrate a poorly sensate but stable and safe bladder with functional obstruction and impaired bladder contractility that may necessitate straining or intermittent self-catheterisation.

High percentage of neurologic deficits in the electrophysiology study of the lower urinary tract in patients with detrusor underactivity and chronic urinary retention.

OBJECTIVES: Both detrusor underactivity (DU) and bladder outlet obstruction are the common causes of chronic urinary retention. Some novel treatment approaches focus on modulating micturition reflex and external urethral sphincter (EUS) function. This study used electrophysiologic (EP) studies to investigate the micturition reflex and EUS conditions of chronic urinary retention patients. METHODS: Sixty patients with urodynamic DU and chronic urinary retention were studied using (1) bulbocavernous reflex (BCR) by electric stimulation, (2) electromyography (EMG) of the EUS, and (3) nerve conduction velocity (NCV) studies of the pudendal nerve. The EP findings were analyzed in DU patients with different etiologies. RESULTS: The BCR was positive in 41.7% of patients. In EMG studies, denervation, reinnervation, and reduced recruitment of the EUS were observed in 21.7%, 71.7%, and 88.3% patients, respectively. Decreased amplitude of pudendal nerve conduction in NCV studies was noted in 73.3% of patients. Patients with sacral neuropathy had a lower BCR positive rate (p = 0.001), a nonsignificant but higher denervation rate (p = 0.059) in EMG studies, and a higher rate of decreased amplitude in NCV (p = 0.011) than those without sacral neuropathy. Excluding patients with sacral neuropathy or diabetes mellitus, a high percentage of neurologic deficits was still detected in EP studies. CONCLUSIONS: Chronic urinary retention patients with urodynamic DU not only have bladder dysfunction, but also potential neuropathy in the sacral reflexes, pudendal nerve, or urethral sphincter innervation. The neurologic deficits explored in EP studies may affect the decision-making around the therapy to restore the voiding function in DU.

A comparison of flow rate curve shape and video-urodynamic findings in women with lower urinary tract symptoms: can flow rate curve shape predict female bladder outflow obstruction or detrusor underactivity?

PURPOSE: To establish the correlation between flow rate curve shape and video-urodynamic findings in women with lower urinary tract symptoms (LUTS). METHODS: A retrospective review of consecutive women with LUTS who performed a free flow study immediately before undergoing video-urodynamic investigations over a 28-month period. Flow rate curve shape and video-urodynamic parameters were analysed. Free flow curves were defined into five categories: bell-shaped, prolonged, fluctuating, intermittent or plateau. Women who voided less than 150 ml on the free flow study were excluded from the analysis. RESULTS: A total of 250 women with LUTS, with a mean age 48 years (range 18-83), were included. Bell-shaped tracings excluded obstruction in 89%. Prolonged flow rate curves diagnosed obstruction in 62% and detrusor underactivity in 8%. Fluctuating and intermittent flow rate curves were associated with urodynamic obstruction in 37 and 39%, respectively, and detrusor underactivity in 25 and 29%, respectively. A plateau flow rate curve was indicative of urodynamic obstruction in all three cases observed. CONCLUSION: Flow rate curve patterns can be suggestive of urodynamic diagnoses. Women without a prolonged void and bell-shaped traces had normal voiding urodynamics in 76% of cases, and the majority could be managed without invasive investigations. Patients with fluctuating and intermittent flow rate curves demonstrate a spectrum of urodynamic diagnoses with a third of cases having obstruction and a third of cases having detrusor underactivity. Plateau flow rate curve patterns are associated with urethral obstruction.

Standardization for reliable uroflowmetry testing in adults.

OBJECTIVES: To assess if a standard hydration protocol will achieve voided volumes over 150 mL and more reliable uroflowmetry results. METHODS: This is a single-blinded crossover study of 40 patients with benign prostatic obstruction and 34 healthy volunteers. Subjects were enrolled prospectively between January and March 2019. All subjects performed two randomly ordered uroflowmetry tests. One test was performed when subjects sensed their bladder was full and had the urge to void and another one after emptying the bladder and ingesting 1.5 L of water within 1 hour (prehydration). Uroflowmetry parameters were compared between the benign prostatic obstruction group and the healthy volunteers. Uroflowmetry results were categorized as reliable, residual, and suboptimal with respect to voided volumes. This study has been registered in the UMIN Clinical Trials Registry (UMIN000035446). RESULTS: The benign prostatic obstruction group and the healthy volunteer group presented no difference in respect of uroflowmetry test reliability (P = .459). Uroflowmetry results were reliable in 58 (78.4%) subjects in the prehydrated group and was reliable in 30 (40.5%) subjects in the non-prehydrated group. The difference was statistically significant (P < .05). In the benign prostatic obstruction group and healthy volunteer group, the rate of reliable uroflowmetry tests was significantly higher with prehydration (P < .05). The comparative analysis of uroflowmetry parameters between tests performed with and without prehydration revealed higher values in the prehydrated group (voided volume, maximum flow rate, average flow rate, and postvoiding residual volume; P < .05). CONCLUSION: Prehydration of patients with 1.5 L of water within 1 hour before uroflowmetry improves uroflowmetry outcomes. By this hydration protocol, the chance to obtain a voided volume over 150 mL is increased significantly.

Is isolated bladder outlet obstruction associated with hydronephrosis? A database analysis.

AIMS: To examine whether isolated bladder outlet obstruction in the absence of associated lower urinary tract abnormality results in hydronephrosis. Isolated obstruction causes a brief rise in bladder pressure that might not trigger hydronephrosis. METHODS: Data included adult men who underwent urodynamics for refractory non-neurogenic lower tract symptoms between 2011 and 2020. International Continence Society indices for obstruction (bladder outlet obstruction index [BOOI] ≥ 40) and underactivity (bladder contractility index [BCI] < 100) were calculated. Storage abnormality was defined as detrusor overactivity (DO) or poor compliance (<20 ml/cm H2 0). Isolated obstruction was defined as BOOI ≥ 40, BCI ≥ 100 and no storage abnormality. Nonparametric tests using R program (3.5.0) applied (p < .05 significant). Logistic regression analyses were performed to study the relationships of hydronephrosis with lower urinary tract function. RESULTS: A total 1596 men (range, 18-91 years; median, 51.0 years; Q3, 64.0 years; Q1, 34.0 years) were eligible. Hydronephrosis was noted in 274 (17.2%). A total of 45.4% were obstructed, 52.3% were underactive and 41.7% had storage abnormality. Storage abnormality (odds ratios [OR], 2.05; 95% confidence interval [CI]: 1.56, 2.69; p < .001) and bladder contractility (OR, 1.68; 95% CI, 1.25-2.26; p < .001) but not obstruction (OR, 1.07; 95% CI, 0.80-1.44; p = .634) was associated with hydronephrosis. Of eight possible combinations, men with BOO ≥ 40, BCI ≥ 100 and storage abnormality had highest probability of hydronephrosis (OR, 0.29; 95% CI, 0.24-0.33). Subanalysis showed that poor compliance (OR, 3.39; 95% CI, 2.49-4.60; p < .001) but not DO was associated with hydronephrosis. Younger age and higher postvoid residual urine were also associated with hydronephrosis. CONCLUSIONS: In adult men with refractory non-neurogenic lower urinary tract symptoms, isolated bladder outlet obstruction is not associated with hydronephrosis.

Female bladder neck dysfunction-A video-urodynamic diagnosis among women with voiding dysfunction.

OBJECTIVE: To investigate bladder neck dysfunction (BND) in women with voiding dysfunction by video-urodynamic study (VUDS) and to examine the therapeutic results of different BND subtypes. MATERIALS AND METHODS: We retrospectively reviewed consecutive women who had undergone VUDS for investigation of voiding dysfunction at our institution. The diagnosis of BND was made based on a nonfunneling bladder neck with or without high voiding detrusor pressure. Patients diagnosed as BND were retrieved, and the urodynamic parameters were compared with patients with dysfunctional voiding (DV) and other bladder outlet obstructions (BOO). RESULTS: Among 810 women with bladder outlet dysfunction, BND was noted in 100 (12.3%), poor pelvic floor relaxation in 336 (41.5%), DV in 325 (40.1%), cystocele in 19 (2%), and urethral stricture in 30 (4%). Compared with the normal tracing group, BND patients had a significantly smaller volume of bladder filling sensation (included first sensation of filling, full sensation and cystometric bladder capaicity) and a greater BOO index (BOOI) (all P < .05). Detrusor overactivity was noted in 46 (46%) BND patients. These urodynamic parameters in BND were not significantly different from patients with DV or other BOO. High-pressure BND had a greater BOOI, but low-pressure BND had a lower voiding efficiency. Both alpha-blocker therapy and transurethral incision of the bladder neck improved uroflow parameters in BND patients. CONCLUSIONS: BND includes 12.3% of women with bladder outlet dysfunction. High-pressure BND can cause anatomical BOO, whereas low-pressure BND is likely to affect micturition through inhibiting detrusor contractility. VUDS is the mainstay diagnostic tool to diagnose BND in women.

Noninvasive Pressure Flow Studies in the Evaluation of Men with Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Review of 50,000 Patients.

PURPOSE: The UroCuff® Test is a noninvasive pressure flow study used to manage men with lower urinary tract symptoms. UroCuff Tests were performed on men with lower urinary tract symptoms to evaluate voiding characteristics and quantify changes in urodynamic parameters with age. MATERIALS AND METHODS: This cross-sectional study included all UroCuff Tests performed at 103 urology practices in the U.S. Tests were de-identified prior to collection and analysis. Inclusion criteria required initial pressure flow study with subsequent tests excluded, voided volume 50 ml or greater, at least 1 cuff inflation and patient age greater than 20 years. Pressure, maximum flow rate, flow rate efficiency (maximum flow rate/Pcuff), voided volume and post-void residual were plotted by age and stratified by Newcastle Noninvasive Nomogram category. RESULTS: A total of 50,680 patients 20 to 100 years old (median age 66.0) met inclusion criteria. Median Pcuff was 144.3 cmH2O and 60.8% of patients were categorized in the obstructed or high pressure/high flow Newcastle Noninvasive Nomogram quadrants. Median maximum flow rate was 10.9 ml per second and 55.8% had maximum flow rate greater than 10 ml per second. Median voided volume and post-void residual were 219.0 and 75.0 ml, respectively. All measures deteriorated with age (p <0.0001). Pcuff reflects the compensated/decompensated bladder function lifecycle. Values initially increased and reached peak pressure at age 62, then decreased by approximately 0.96 cmH2O per year until age 90. CONCLUSIONS: This study demonstrates that symptomatic patients enter urological practices at different urodynamic stages of bladder function and outlet obstruction, that Pcuff, maximum flow rate, voided volume, flow rate efficiency and post-void residual deteriorate with age, and that UroCuff is a sensitive evaluation of bladder performance.

Labial adhesion in a postmenopausal female: A case report.

RATIONALE: Voiding difficulty is more common in males, although it is not uncommon in females. Female voiding difficulty can be caused by iatrogenic, anatomic, and neurogenic factors, and specifically urethra stricture, impaired detrusor contractility, primary bladder neck obstruction, and detrusor-external sphincter dyssynergia. Labial adhesion is a rare cause of female voiding difficulty.The incidence of labial fusion has been reported to be 0.6% to 1.4% in children; however, the incidence in the elderly has yet to be fully elucidated. PATIENT CONCERNS: We present the case of a postmenopausal and sexually inactive 76-year-old female patient who had nearly total vaginal and urethral occlusion due to labial adhesion. She had no underlying diseases and came to our clinic with a 10-month history of voiding difficulty, postmicturition dribbling, and involuntary urinary leakage when getting up. DIAGNOSIS: A genital examination revealed nearly total fusion of the labia minor with only a 3-mm pinhole opening at the posterior end. INTERVENTIONS: Treatment included surgical separation, the local application of estrogen cream, and self-dilatation. She also received an antimuscarinic agent to treat overactive bladder secondary to bladder outlet obstruction which was caused by labial adhesion. OUTCOMES: No surgical complications occurred. Moreover, no labial adhesion or voiding dysfunction was found immediately after the surgery or after 6 months of follow-up. LESSONS SUBSECTIONS: Genital examinations are a basic but very important noninvasive skill for physicians. This case report highlights that genital examinations should be a priority for patients with gynecological or urological symptoms.

Long-term tadalafil administration can prevent functional and structural changes of the urinary bladder in male rats with partial bladder outlet obstruction.

AIMS: There have been few reports on whether long-term oral phosphodiesterase 5 inhibitor administration can ameliorate bladder changes due to bladder outlet obstruction (BOO). Therefore, we clarified the chronological changes of the bladder using male BOO rats and evaluated the effects of tadalafil on these changes. METHODS: Eight-week-old male Sprague-Dawley rats were used. BOO was created by placing a polyethylene catheter around the urethra. Then, the rats were orally treated with a vehicle, or tadalafil 2 or 10 mg/kg until each evaluation period. Cystometric measurements were performed and the degree of fibrosis in the smooth muscle layer was evaluated at 2, 4, and 16 weeks. RESULTS: In BOO rats, a significant increase in the number of non-voiding contractions (NVCs) and a shortened intercontraction interval (ICI) were observed in the earlier phase (2 and 4 weeks) compared to Sham rats. In the chronic phase (16 weeks), markedly increased residual urine volume and an extended ICI were observed accompanied by enhanced smooth muscle fibrosis. These results indicated that the bladder in BOO rats represented the overactive phenotype in the earlier phase and changed into the underactive phenotype in the chronic phase. Even in Sham rats, an increased number of NVCs and enhanced fibrosis were observed with time. Tadalafil administration significantly prevented these bladder changes in both BOO and Sham rats. CONCLUSIONS: Long-term oral administration of tadalafil can prevent functional and histological changes in the BOO rat bladder. This agent is also effective for the bladder functional change even in non-obstructed rats.

Treatment validation of the Solomon-Greenwell nomogram for female bladder outlet obstruction.

AIM: Bladder outflow in women (bladder outlet obstruction [BOO]) has no well-accepted defining diagnostic criteria. Various nomograms exist based on flow rates, pressure-flow data, and fluoroscopy. We have prospectively evaluated the Solomon-Greenwell bladder outflow obstruction nomogram (SG BOO nomogram) as a measurement of BOO resolution following targeted surgical intervention. METHODS: The routine posttreatment urodynamics of 21 unselected women with an original urodynamic diagnosis of BOO on fluoroscopy and the SG BOO nomogram (BOO boundary defined as Qmax > 2.2 Pdet.Qmax + 5) were reviewed. All women had symptomatic BOO secondary to anterior pelvic organ prolapse (aPOP), urethrovaginal fistula (UVF), previous stress urinary incontinence (SUI) surgery, urethral stricture (US), or urethral diverticulum (U Div). Following treatment, all presenting symptoms resolved and simple urodynamics were performed as part of routine follow-up. RESULTS: The urodynamic findings preoperatively and postoperatively showed statistically significant changes posttreatment in mean flow rate which increased from 9.38 to 14.71 mL/s, mean Pdet.Qmax which decreased from 38 to 18.38 cmH2 O, and mean SG BOO nomogram probability (PBOO) which reduced from PBOO = 0.68 to 0.08. Mean SG BOO nomogram PBOO was significantly reduced posttreatment in all individual categories except UVF where a nonsignificant reduction from PBOO = 0.55 to 0.05 occurred. CONCLUSIONS: All urodynamic parameters significantly improve in women who become asymptomatic following surgical treatment of BOO. This improvement is best demonstrated by the change in probability of BOO according to the Solomon-Greenwell nomogram. These findings underline the validity of the Solomon-Greenwell female BOO nomogram for diagnosing and monitoring BOO in women.

Quality control of uroflowmetry and urodynamic data from two large multicenter studies of male lower urinary tract symptoms.

AIM: The International Continence Society (ICS) has standardized quality control and interpretation of uroflowmetry and urodynamics. We evaluated traces from two large studies of male lower urinary tract symptoms (UPSTREAM and UNBLOCS) against ICS standards of urodynamic equipment and practice. METHODS: Ten percent of uroflowmetry and urodynamics traces were selected at random from hospital sites. A data capture template was designed from the ICS Fundamentals of Urodynamic Practice checklist. Two pretrained blinded assessors extracted the data, with a third assessor to arbitrate. Departmental records of calibration checks and equipment maintenance were scrutinized. RESULTS: Seven out of twenty-five (28%) departments reported no calibration checks. Four sites (16%) could not provide annual service records. In 32 out of 296 (10.8%) uroflowmetry traces, findings were affected by artifact. One hundred ten urodynamic study traces were reviewed; in 11 records (10%), key pressure traces were incompletely displayed. In 30 (27.2%), reference zero was not set to atmospheric pressure. Resting pressures were outside the expected range for 36 (32.7%). Pressure drift was seen in 18 traces (16.4%). At pressure-flow study commencement, permission to void was omitted in 15 (13.6%). Cough testing after voiding was done in 71.2%, but the resulting cough spikes were significantly different in 16.5%. Erroneous diagnosis of bladder outlet obstruction (BOO) was identified in six cases (5.5%). CONCLUSIONS: Erroneous diagnosis of BOO is a serious error of interpretation, as it could lead to unnecessary surgery. Other errors of standardization, testing, and interpretation were identified with lower risk of adverse implications. Inconsistent documentation of service records mean equipment accuracy is uncertain.

Reduced Ca2+ spark activity contributes to detrusor overactivity of rats with partial bladder outlet obstruction.

We tested whether or not altered Ca2+ spark activity accounted for detrusor overactivity (DO) of Wistar rats after partial bladder outlet obstruction (PBOO). We constructed a DO model through PBOO and studied the Ca2+ spark activity of detrusor. By way of using confocal microscopy and the patch-clamp technique, Ca2+ sparks and spontaneous transient outward currents (STOCs) in detrusor myocytes were measured respectively. Our results indicated that Ca2+ spark activity and STOCs were significantly reduced in the DO detrusor myocytes compared to unafflicted control cells, and both of these had levels that were remarkably increased by applications of caffeine (10 µM), a RyR agonist, in DO myocytes. In addition, measures of detrusor contractions were also recorded by using freshly isolated detrusor strips. These results indicated that the spontaneous contraction of DO detrusor was significantly enhanced, and that the effect of caffeine (10 µM) upon detrusor contractions was reversed by applications of iberiotoxin (100 nM) which is a BK channel blocker. Western blotting (WB) analyses indicated that the levels of expression of ryanodine receptor type 2 (RyR2) and FK506 binding protein 12.6 (FKBP12.6) in bladder muscle were respectively decreased and increased in the samples from DO rats. Thus, we considered in the rat DO model wherein PBOO, the reduced Ca2+ spark activity in detrusor myocytes partly contributed to overactive detrusor contractions. The impaired Ca2+ spark activity may have resulted from decreased RyR2 expression and increased FKBP12.6 expression. Such novel findings in our research might help to provide means for better treatment outcomes for patients afflicted by bladder dysfunction.