[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.

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.

[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.

Sexual dysfunction in men with multiple sclerosis--a comprehensive pilot-study into etiology.

UNLABELLED: Ideally, the etiological diagnosis of sexual dysfunction in patients with multiple sclerosis is established on the basis of both objective and subjective tests. Accordingly, we assessed sexual function in 16 male patients with multiple sclerosis and complaints of sexual dysfunction by means of subjective data from interviews and questionnaires and objective data, obtained from (psycho)physiological tests. Psychophysiological investigation consisted of measurement of sleep erections and of erectile response to visual erotic stimulation and penile vibration. Urodynamic investigation was used to assess the neurological status of the genital tract. Sixteen male patients with clinically definite multiple sclerosis, complaints of sexual dysfunction and a steady heterosexual relationship participated in the study. The majority of patients had no abnormalities in the objective tests. Only one (1 out of 15) patient showed disturbed sleep-erections, and four (4 out of 12) other patients showed signs of neurological dysfunction of the genital tract. CONCLUSION: In our patient-group, disturbed sleep erections and abnormal findings on urodynamic investigation appeared unrelated to the complaint of erectile dysfunction. Sexual function was related to psychological factors, decreased general sensitivity, and motor impairment.

A computer model for describing the effect of urethral afferents on simulated lower urinary tract function.

A computer model of mechanical properties of the bladder, the urethra and the rhabdosphincter, as well as their neural control is presented in this paper. The model has a rather simple design and processes sensory information from both the bladder wall tension and urethral stretch. It is assumed that afferent signals from the urethra are involved in a sacral excitatory reflex and a supraspinal inhibitory reflex. Pressure and flow signals that resemble experimentally measured normal human behaviour could be simulated with this model. From these simulations the relation between the neural control mechanisms used in the model and the neural control mechanism in vivo cannot be judged entirely because similar behaviour could be simulated with models that are bas ed on different neural control mechanisms. Also behaviour that resembles detrusor overactivity was simulated with our model after an externally induced rise in detrusor pressure was added. Detrusor overactivity, sometimes in combination with urethral relaxation, can occur during a urodynamic investigation. A possible explanation for this detrusor overactivity might be that the micturition reflex is triggered by unknown disturbances and is inhibited immediately after by the same mechanism that normally ceases voiding. The described model provides such a mechanism. Based on these simulations, therefore, it is concluded that urethral afferent signals might be important in lower urinary tract control.

[Guideline 'Chronic heart failure']. / Richtlijn 'Chronisch hartfalen'.

A new Dutch clinical practice guideline has been developed for the diagnosis, treatment and supportive care of patients with chronic heart failure. This has been formulated by a multidisciplinary working group, set up by the Netherlands Heart Foundation and the Netherlands Society of Cardiology, in cooperation with the Dutch Institute for Healthcare Improvement. Heart failure is defined as: 'a complex of complaints and symptoms resulting from an inadequate pumping function of the heart'. Indications for heart failure are dyspnoea on exertion, reduced exertion tolerance and oedema. By using data from the medical history, case history, physical examination and simple additional tests (laboratory tests, ECG, chest X-ray photos) it is possible to demonstrate or exclude heart failure in clear-cut cases. Doppler ultrasonography should be performed in all patients where heart failure is suspected but cannot be clearly demonstrated. The initial treatment for patients with heart failure with reduced systolic LV function generally consists of the administration of a thiazide or loop diuretic together with an angiotensin-converting enzyme inhibitor and a beta-blocker, to which digoxin and/or spironolactone may be added. For very old patients extra attention should be given to the comorbidity and the medication and dosing scheme should be as simple as possible. The worse the cardiac function, the more the salt and fluid intake should be limited and the more strictly the weight should be monitored.

Is there a correlation between prostate size and bladder-outlet obstruction?

This retrospective study was conducted in 521 men with micturition complaints to determine the relationship between prostate size and bladder-outlet obstruction. Analysis showed a statistically significant correlation between bladder-outlet obstruction and prostate size. Urodynamic bladder-outlet obstruction was confirmed in 90% of the patients with a prostate size of more than 80 cm3. In 32% of the patients with a prostate smaller than 40 cm3, no urodynamic evidence of bladder-outlet obstruction was found. There was no correlation between symptom scores (Madsen and I-PSS) and the grade of bladder-outlet obstruction or prostate size. We conclude that precise determination of the prostate size and urodynamics investigations are important (complementary) parameters in the assessment of elderly men with micturition complaints.

Comparison of different computer models of the neural control system of the lower urinary tract.

This paper presents a series of five models that were formulated for describing the neural control of the lower urinary tract in humans. A parsimonious formulation of the effect of the sympathetic system, the pre-optic area, and urethral afferents on the simulated behavior are included. In spite of the relative simplicity of the five models studied, behavior that resembles normal lower urinary tract behavior as seen during an urodynamic investigation could be simulated. The models were tested by studying their response to disturbances of the afferent signal from the bladder. It was found that the inhibiting reflex that results from including the sympathetic system or the pre-optic area (PrOA) only counteracts the disturbance in the storage phase. Once micturition has started, these inhibiting reflexes are suppressed. A detrusor contraction that does not result in complete micturition similar to an unstable detrusor contraction could be simulated in a model including urethral afferents. Owing to the number of uncertainties in these models, so far no unambiguous explanation of normal and pathological lower urinary tract behavior can be given. However, these models can be used as an additional tool in studies of the mechanisms of the involved neural control.

Bladder compliance after posterior sacral root rhizotomies and anterior sacral root stimulation.

To evaluate the effects of central detrusor denervation on bladder compliance, we studied 27 patients with complete suprasacral spinal cord injury in whom intradural posterior sacral root rhizotomies from S2 to S5 in combination with implantation of an intradural Finetech-Brindley bladder stimulator were performed. All patients initially presented with detrusor hyperreflexia. A majority of these patients had a decreased bladder compliance 5 days postoperatively followed by a rapid increase in bladder compliance thereafter. All patients showed persistent detrusor areflexia after long-term followup. In 2 patients incomplete posterior sacral rhizotomies appeared to be performed. These patients had low bladder compliance, so that secondary posterior sacral root rhizotomies at the level of the conus medullaris were done. Intradural rhizotomies of all posterior sacral root components from S2 to S5 in combination with implantation of an anterior sacral root stimulator is a safe and effective procedure in spinal cord injury patients.

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.

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.

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.

A computer model of the neural control of the lower urinary tract.

Better understanding of the underlying working mechanism of the neural control of the lower urinary tract will facilitate the treatment of dysfunction with a neurogenic cause. We developed a computer model to study the effect of a neural control system on lower urinary tract behavior. To model the mechanical properties and neural control, assumptions had to be made. These assumptions were based, as much as possible, on knowledge and hypotheses taken from the literature. With valid assumptions, it should be possible to simulate normal as well as pathological behavior. To test the computer model, first, normal behavior of the lower urinary tract was simulated, and secondly, the known features of bladder outlet obstruction were simulated after the properties of the urethra were changed. The simulation results are comparable with measured data, so the assumptions on which the model is based could be valid. If the assumptions are valid, the feedback loops used in the model are also important feedback loops in vivo, and the model can be used to gain insight into the underlying mechanism of neural control.

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.

Results of the treatment of neurogenic bladder dysfunction in spinal cord injury by sacral posterior root rhizotomy and anterior sacral root stimulation.

PURPOSE: We evaluated the results of treatment of neurogenic bladder dysfunction in spinal cord injury by sacral posterior root rhizotomy and anterior sacral root stimulation using the Finetech-Brindley stimulator. MATERIALS AND METHODS: In 52 patients with spinal cord lesions and urological problems due to hyperreflexia of the bladder complete posterior sacral root rhizotomy was performed and a Finetech-Brindley sacral anterior root stimulator was implanted. All patients were evaluated and followed with a strict protocol. A minimal 6-month followup is available in 47 cases. RESULTS: Complete continence was achieved in 43 of the 47 patients with 6 months of followup. A significant increase in bladder capacity was attained in all patients. Residual urine significantly decreased, resulting in a decreased incidence of urinary tract infections. In 2 patients upper tract dilatation resolved. In 3 patients rhizotomy was incomplete and higher sectioning of the roots was necessary. One implant had to be removed because of infection. CONCLUSIONS: The treatment of neurogenic bladder dysfunction in spinal cord injury by anterior sacral root stimulation with the Finetech-Brindley stimulator in combination with sacral posterior root rhizotomy provides excellent results with limited morbidity.

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.

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.

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.