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Diagnosis: Urology

Epidemiological aspects of recruitment of male volunteers for non-invasive urodynamics.

Avagyan V, van Mastrigt R, Huang Foen Chung JW, Bohnen AM, Bosch JL, Mulder PG
Urol Int. 2006;77(2):159-65.

INTRODUCTION: We studied epidemiological aspects of recruitment of volunteers for a non-invasive urodynamic study. MATERIALS AND METHODS: 9,236 volunteers were invited by 20 general practitioners (GPs), using two different recruitment methods, i.e. by mail only, or during a subsequent visit to the GP's office. Factors influencing the response rates were analyzed. We also tested how much the recruited population of volunteers differed from the general population, by comparing it to another, proven representative study carried out earlier in 1,662 subjects. RESULTS: In the recruited population the prostate volumes were not significantly different from the proven representative study, but the symptom score was statistically significantly higher, although the difference was so small it may be called clinically irrelevant. Recruitment of volunteers in two steps, i.e. asking them first to visit the GP's office, and inviting them there to visit the outpatient clinic, rather than directly inviting them (in writing) to the clinic seemed to lead to a higher response, although this effect could not be statistically discriminated from the difference in response rates between GPs. CONCLUSION: The population recruited was not urologically different from the general population. The response depended on age, being highest around the age of 60, and increased with social economic status. It also depended on the GP who recruited the subjects, and/or on the recruitment method.

[May the Blaivas and Groutz nomogram substitute videourodynamic studies in the diagnosis of female lower urinary tract obstruction?]
Virseda Chamorro M, Salinas Casado J, Adot Zurbano JM, Martin Garcia C
Arch Esp Urol. 2006 Jul-Aug;59(6):601-6.

OBJECTIVES: To compare the results of the Blaivas and Groutz nomogram in the diagnosis of female urinary obstruction with videourodynamic tests. METHODS: We performed a transverse study in a series of 52 female patients with ages between 20 and 81 years (mean age: 48.7 years; standard deviation: 14.4 years) and functional lower urinary tract symptoms referred for videourodynamic studies. All patients underwent free flowmetry and voiding videourodynamic study. From the scores of free flowmetry and maximum detrusor pressure in the detrusor pressure/voiding flow test of the urodynamic study they were classified in one of four categories following the Blaivas and Groutz nomogram. Following urodynamic data they were classified into three categories: absence of obstruction, bladder neck obstruction and urethral obstruction. The nomogram results were compared with the videourodynamic data using the Pearson chi-square statistical test. The diagnostic sensitivity and specificity of the nomogram were also determined. RESULTS: The Blaivas and Groutz nomogram showed a significant association with the videourodynamic data (p = 0.000). Its diagnostic sensitivity for obstruction was 100%, but its specificity was only 67.5%. The percentage of diagnostic discrepancies was maximal in the mild obstruction, where one third of the patients were obstructed following the videourodynamic data. CONCLUSIONS: The Blaivas and Groutz nomogram is a sensitive method for the diagnosis of obstruction, but its specificity is low so that it has the tendency to overdiagnose the presence of obstruction in the female patient.

The relationship of urethral resistance pressure and pressure flow parameters in women with lower urinary tract symptoms.
Digesu GA, Chaliha C, Khullar V, Salvatore S, Milani R, Cacciapuoti C, Athanasiou S
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug 10;. e-pub

This prospective study aims to evaluate the relationship between urethral resistance pressure (URP) and pressure flow parameters in women with lower urinary tract symptoms (LUTS). Consecutive women with LUTS attending three tertiary referral urodynamic clinics were asked to undergo urodynamic evaluation, pressure flow studies and URP measurement. The pressure flow parameters such as detrusor pressures at the start of flow (ODP), detrusor pressure at peak flow rate (PdetQmax), peak flow rate (Qmax) and detrusor pressure at the end of flow (CDP) were measured. The relationship between URP and pressure flow parameters was evaluated as well as differences between each urodynamic group. Two hundred seventy-nine women attended for urodynamic investigations. Two hundred twenty-three (79.9%) women had good quality pressure flow measurements and were included in the study. The mean age was 58 years (range 21-83). Women with urodynamic stress incontinence had significantly lower URP and ODP than those with detrusor over-activity [54.8 (+/-17.9) and 12.4 (+/-4.1) cmH(2)O, respectively, vs 85.6 (+/-21.4) and 33.7 (+/-13.3) cmH(2)O, respectively) (p<0.05, Bonferroni test). Furthermore, women with urodynamic stress incontinence have significantly lower PdetQmax values as well as higher Qmax than women with competent urethral sphincters (p<0.05, Bonferroni test). There was a significant correlation between ODP, PdetQmax, Qmax and URP measurements. In urodynamic stress incontinence, both URP and pressure flow parameters are reduced. Although the trend for values of both tests were similar and there was a significant correlation between these tests, we should consider that urethral function at rest differ from that during voiding due to activation of additional mechanisms. Therefore, further study is needed to confirm our results.

Weak VLPP and MUCP correlation and their relationship with objective and subjective measures of severity of urinary incontinence.
Martan A, Masata J, Petri E, Svabik K, Drahoradova P, Voigt R, Pavlikova M, Hlasenska J
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Aug 5;.

The aims of the present study were to find the correlation between Valsalva leak-point pressure (VLPP) and cough leak-point pressure (CLPP) and to determine whether the water perfusion maximum urethral closure pressure (MUCP) correlates with VLPP. Seventy-nine women with previously untreated stress urinary incontinence were recruited to participate in a clinical study. Their mean age was 56.4 years, mean BMI was 27.8, and mean parity was 1.9. The mean values of VLPP and CLPP were 50.4 and 52.9 cm H(2)O, respectively. We did not find statistically significant differences in the mean values of VLPP and CLPP. The mean value of MUCP at rest was 44.2 cm H(2)O and the mean value of MUCP during maximal Valsalva maneuver was 37.2 cm H(2)O; with 500 ml of sterile saline in the bladder the difference between them is statistically significant. In the study group (n=79), 56 patients (77%) had low VLPP (</=60 cm H(2)O), 21 patients (30%) had low MUCP (</=30 cm H(2)O), and 8 patients had MUCP</=20 cm H(2)O (all at rest). Of the 56 patients with low VLPP, 16 also had a low MUCP (</=30 cm H(2)O). This study mainly compares two parameters-the MUCP and the VLPP. Based on our results we can conclude that there is no correlation between these parameters. MUCP measures urethral resistance at rest and VLPP measures urethral resistance during increased intra-abdominal pressure (Valsalva maneuver).

Automatic switching and guidance system to facilitate unassisted uroflowmetry using commercial electronic devices.
Terai A, Ueda N, Utsunomiya N, Kohei N, Aoyama T, Inoue K
Int J Urol. 2006 Aug;13(8):1154-5.

To enable male patients to undergo uroflowmetry in a private condition without medical supervision, we devised an automatic switching and patient guidance system for the spinning disk uroflowmeter Urodyn 1000, using two commercial electronic devices (an infrared motion sensor tap and a memorizable vacuum fluorescent display). Instead of running the uroflowmeter continuously, which shortens the life of the spinning disk due to mechanical wear, an infrared motion sensor turns on the devices each time a patient enters the room. The patient urinates according to the timely instructions on the visible display and voided urine directly flows into a urinal. The devices are automatically turned off 5 min after the patient leaves the room. With the use of our system, men already acquainted with uroflowmetry could perform self-administered uroflowmetry any time in private. The system was considered useful for improving the quality of patient service.

Urological survey: Imaging.
Siegel C
J Urol. 2006 Sep;176(3):951.

Urological survey: Imaging.
Siegel C
J Urol. 2006 Sep;176(3):1018-9.

Re: Interstitial cystitis versus detrusor overactivity: a comparative, randomized, controlled study of cystometry using saline and 0.3 m potassium chloride. J. Philip, S. Willmott and P. Irwin. J Urol, 175: 566-571, 2006.
Parsons CL
J Urol. 2006 Sep;176(3):1253-4; author reply 1254.

Reply by authors.
J Urol. 2006 Sep;176(3):1253.

Urodynamic effects of intravesical administration of the new small/intermediate conductance calcium activated potassium channel activator NS309 in freely moving, conscious rats.
Pandita RK, Ronn LC, Jensen BS, Andersson KE
J Urol. 2006 Sep;176(3):1220-4.

PURPOSE: We investigated the effects of the new K+ channel activator NS309, which acts on small and intermediate conductance Ca2+ activated K+ channels, on detrusor activity in normal rats. MATERIALS AND METHODS: NS309 was given intravesically at different concentrations to conscious female Sprague-Dawley rats undergoing continuous cystometry. The effects of the drug on oxyhemoglobin induced detrusor overactivity were also tested. RESULTS: Intravesical NS309 (100, 300 and 1,000 ng ml(-1)) increased bladder capacity, micturition volume and intercontraction intervals in a concentration dependent way. NS309 (1,000 ng ml(-1)) given intravesically for 1 hour before instillation of intravesical oxyhemoglobin (250 microM) decreased or completely prevented the detrusor overactivity induced by oxyhemoglobin. CONCLUSIONS: Opening small and intermediate conductance Ca2+ activated K+ channels with NS309 given intravesically increased bladder capacity, micturition volume and intercontraction intervals in a concentration dependent way and prevented oxyhemoglobin induced detrusor overactivity. Results suggest that these channels can be interesting targets for drugs aiming to control micturition.


Reliability and agreement of urodynamics interpretations in a female pelvic medicine center.
Whiteside JL, Hijaz A, Imrey PB, Barber MD, Paraiso MF, Rackley RR, Vasavada SP, Walters MD, Daneshgari F
Obstet Gynecol. 2006 Aug;108(2):315-23.

OBJECTIVE: To estimate the reliability and interobserver consistency of urodynamic interpretations of female bladder and urethral function. METHODS: Three urogynecologists and three female urologists at a tertiary care medical center reviewed masked, abstracted clinical and urodynamic information from 100 charts, selected for adequate completeness from a consecutive series of 135 women referred for urodynamic testing. For each of the 100 cases, the reviewers assigned International Continence Society filling and voiding phase diagnoses, and overall clinical diagnoses. Raw agreement proportions and weighted kappa chance-corrected agreement statistics (kappa) were used jointly to describe both reliability and interobserver agreement. Reliability was estimated from duplicate reviews, masked and separated by at least 4 months, of each case by each physician. Interobserver agreement was estimated from comparisons of all pairs of responses from different physicians. RESULTS: For clinical diagnosis of stress incontinence (present, absent, indeterminate), the within- and across-physician weighted kappa's were, respectively, 0.78 and 0.68. Corresponding results were 0.40 and 0.13 for detrusor overactivity without incontinence, 0.58 and 0.38 for detrusor overactivity with incontinence, and 0.51 and 0.26 for voiding dysfunction. Standard errors of each kappa were between 0.023 and 0.043. CONCLUSION: In our group, lower urinary tract diagnoses of stress urinary incontinence from both clinical and urodynamic data demonstrated substantial reliability and interobserver agreement. However, by conventional interpretation of kappa-statistics, reliability of diagnoses of detrusor overactivity or voiding dysfunction was only moderate, and interobserver agreement on these diagnoses was no better than fair. Urodynamic interpretations may not be satisfactorily reproducible for these diagnoses. LEVEL OF EVIDENCE: II-2.

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[Evolution of the transrectal ultrasound guided prostatic biopsy technique]
Herranz Amo F, Diez Cordero JM, Cabello Benavente R
Arch Esp Urol. 2006 May;59(4):385-96.

To analyze the various techniques of transrectal ultrasound guided biopsy of the prostate described in the literature, as well as the anesthesia modalities for its performance. The diagnostic yield of the classic sextant biopsy, described 16 years ago and considered the standard technique ever since, has been overcome by the extended biopsy techniques (greater number of cores from more prostatic areas in each biopsy). Although their intra-study yield is better than sextant biopsy, the scarce randomized studies have not demonstrated a statistically significant improvement. These new techniques of extended biopsy significantly increase the rate of minor complications, not the major. It has not been demonstrated an increase in either the perception of pain or the diagnosis of non-significant tumors. Any anesthetic technique employed diminishes significantly the perception of pain by the patient. The periprostatic nerve blockage with infiltration of lidocaine is better than the rest of the techniques. The best technique of infiltration and the most effective lidocaine dose are to be defined yet. These techniques do not increase complications and only prolong the procedure briefly.

[Tridimensional ultrasound of the prostate]
Bermudez Villaverde R, Marron Penon MC, Arnaiz Esteban F, Martinez Perez E, Espuela Orgaz R
Arch Esp Urol. 2006 May;59(4):377-84.

OBJECTIVES: To present the examination technique of grayscale tridimensional transrectal prostatic ultrasound and its clinical viability. To define the ultrasonographic patterns and to report the clinical experience of our group. METHODS: We analyze selected exams from a database of more than 600 digitally stored tridimensional transrectal prostatic ultrasounds performed with a robotic probe. We collect the opinion and observations of the examiners, all of them experts on prostatic ultrasound. Each case has been completed with pathologic and clinical data. RESULTS: The time spent for each test was less than three minutes, achieving good quality, reproducible exams. The analysis of the front view offers the greatest contribution in comparison to the conventional technique, allowing a more clear detection of structures such as the junction with the seminal vesicles, the capsular contour, and urethra. CONCLUSIONS: Tridimensional transrectal prostatic ultrasound is an imaging test applicable in the clinical practice which offers quality images and may provide great benefits for the diagnosis and local staging of prostate cancer, by means of the analysis of the front view.

[Diagnosis and follow-up of benign prostatic hyperplasia by ultrasound]
Garcia Navas R, Sanz Mayayo E, Arias Funez F, Rodriguez-Patron R, Mayayo Dehesa T
Arch Esp Urol. 2006 May;59(4):353-60.

OBJECTIVES: The aim of the study is to analyze the utility of ultrasound in the evaluation and treatment selection of patients with benign prostatic hyperplasia (BPH). METHODS: A total of 5000 patients older than 50 years and with prostatic symptoms were evaluated with abdominal ultrasound and in selected cases with transrectal ultrasound. RESULTS: The first ultrasonographic sign of BPH is the increase of anteroposterior and longitudinal diameters. Prostatic volume is measured with a safety of 80%, post-void volume and indirect signs of bladder obstruction are also determined by ultrasound. Upper urinary tract pathological conditions can be also detected. CONCLUSIONS: Ultrasound associated with PSA and urinary flow are adequate to evaluate and select treatment in patients with BPH.

Role of transrectal ultrasonography in the prediction of prostate cancer: artificial neural network analysis.
Lee HJ, Kim KG, Lee SE, Byun SS, Hwang SI, Jung SI, Hong SK, Kim SH
J Ultrasound Med. 2006 Jul;25(7):815-21.

OBJECTIVE: The purpose of this study was to evaluate the diagnostic performance of an artificial neural network (ANN) model with and without transrectal ultrasonographic (TRUS) data. METHODS: Six hundred eighty-four consecutive patients who had undergone TRUS-guided prostate biopsy from May 2003 to January 2005 were enrolled. We constructed 2 ANN models. One (ANN_1) incorporated patient age, digital rectal examination findings, prostate-specific antigen (PSA) level, PSA density, transitional zone volume, and PSA density in the transitional zone as input data, whereas the other (ANN_2) was constructed with the above and TRUS findings as input data. The performances of these 2 ANN models according to PSA levels (group A, 0-4 ng/mL; group B, 4-10 ng/mL; and group C, >10 ng/mL) were evaluated using receiver operating characteristic analysis. RESULTS: Of the 684 patients who underwent prostate biopsy, 214 (31.3%) were confirmed to have prostate cancer; of 137 patients with positive digital rectal examination results, 60 (43.8%) were confirmed to have prostate cancer; and of 131 patients with positive TRUS findings, 93 (71%) were confirmed to have prostate cancer. In groups A, B, and C, the AUCs for ANN_1 were 0.738, 0.753, and 0.774, respectively; the AUCs for ANN_2 were 0.859, 0.797, and 0.894. In all groups, ANN_2 showed better accuracy than ANN_1 (P < .05). CONCLUSIONS: According to receiver operating characteristic analysis, ANN with TRUS findings was found to be more accurate than ANN without. We conclude that TRUS findings should be included as an input data component in ANN models used to diagnose prostate cancer.

Urodynamic studies in the evaluation of young men presenting with lower urinary tract symptoms.
Toh KL, Ng CK
Int J Urol. 2006 May;13(5):520-3.

AIM: To evaluate the usefulness of urodynamic study in young men with lower urinary tract symptoms (LUTS). METHODS: We reviewed the charts of 50 men with LUTS aged 50 years and below. Those with neurological diseases, urethral trauma or strictures were excluded. All underwent multichannel urodynamic studies (UDS). The pre- and post-UDS diagnoses and treatment modalities were compared. RESULTS: Mean age was 38.1 years (17-49). The main pre-UDS diagnoses included prostatitis in seven (14%), overactive bladder in seventeen (34%) and benign prostatic hyperplasia in nine (18%). Pre-UDS management ranged from anticholingeric agents for thirteen (26%), alpha-adrenergic antagonists for nine (18%), antibiotics for six (12%). Abnormal UDS were noted in 36 (72%), including detrusor overactivity in 9 (18%), detrusor underactivity/acontractility in 5 (10%) and bladder outlet obstruction in 21 (42%). Fourteen (28%) had primary bladder neck dysfunction and five (10%) had benign prostatic hyperplasia. Post-UDS management included anticholingeric agents for ten (26%), alpha-adrenergic antagonists for seventeen (34%), catheterization for four (10%), behavioral therapy for three (6%), surgery for three (6%). None were prescribed antibiotics. Following UDS, the diagnosis had to be updated in 40 (80%) and concomitant change in management was required in 34 (68%). CONCLUSION: Young men presenting with LUTS have different underlying etiologies. Clinical diagnosis and treatment are often empiric and inaccurate. Urodynamic study is useful in the evaluation of this group of patients as it aids in arriving at an accurate diagnosis and guides treatment therapy.

Frequency of ureteroscope damage seen at a tertiary care center.
Carey RI, Gomez CS, Maurici G, Lynne CM, Leveillee RJ, Bird VG
J Urol. 2006 Aug;176(2):607-10.

PURPOSE: There is controversy regarding ureteroscope durability. Little is known regarding the subsequent durability of a flexible ureteroscope after major damage has been incurred and the ureteroscope has been repaired. Maintenance and repair are associated with significant cost. We reviewed and assessed the frequency and cause of ureteroscope damage at our medical center. MATERIALS AND METHODS: From December 2001 we prospectively recorded the specific use of all ureteroscopes and any resultant damage at a single tertiary care institution. We then reviewed a total of 601 ureteroscopic cases involving 654 semirigid and flexible ureteroscope uses from December 2001 to November 2004. Cases were performed by multiple residents and fellows under the supervision of 3 attending urologists (CML, RJL and VGB). Retrograde and antegrade cases involving stones, urothelial carcinoma, strictures and diagnostic evaluations were included. Repairs for the respective ureteroscopes were performed by the original manufacturer. RESULTS: A total of 53 reports of damage (8.1% of total uses) were recorded. Major damage when the scope was deemed unusable and required repair was seen in 39 cases (6.0%). Four newly purchased flexible ureteroscopes were entered into the study and they provided 40 to 48 uses before the initial repair was needed. After these new ureteroscopes underwent comprehensive repair for major damage they averaged only 11.1 uses (median 8) before needing repair again. Older model ureteroscopes that underwent repair before being entered into our study averaged between 4.75 and 7.7 uses before being sent for subsequent repair. Of the total of 39 breakages 39 for which ureteroscopes were sent for repair 14 (35.9%) were the result of errant laser firing, 11 (28.2%) were the result of excessive torque, 8 (20.5% 8) were the result of decreased flexion in the distal tip or another loss of function without obvious iatrogenic cause, 3 (7.7%) were the result of multifocal catastrophic damage involving laser firing and excessive torque, and 3 (7.7%) were the result of cleaning and processing outside of the ureteroscopy suite. CONCLUSIONS: The most important risk factors for predicting the number of uses expected from a ureteroscope at our institution is ureteroscope age and whether the ureteroscope has undergone comprehensive repair as the result of prior damage. Our analysis suggests that after damage occurs to a ureteroscope more damage occurs with greater frequency. The cost of maintaining previously used ureteroscopes should be carefully considered in comparison to the cost of purchasing a new ureteroscope.

Efficiency of questionnaires used to screen for interstitial cystitis.
Kushner L, Moldwin RM
J Urol. 2006 Aug;176(2):587-92.

PURPOSE: Questionnaires for the evaluation of interstitial cystitis are widely used, but their value in discriminating interstitial cystitis from other diagnoses among patients with urological symptoms has not been determined. We assessed the validity of 2 frequently used interstitial cystitis questionnaires-the O'Leary-Sant Symptom Index and Problem Index and the Pain, Urgency, Frequency Symptom Scale-for screening for interstitial cystitis. MATERIALS AND METHODS: The Pain, Urgency, Frequency Symptom Scale and the O'Leary-Sant Symptom Index and Problem Index were administered to the same 220 patients at a urology clinic before diagnosis. Questionnaire scores between patients with and without interstitial cystitis, as well as among diagnostic groups, were compared by parametric and nonparametric analyses. Receiver operating characteristic curves were constructed to determine the efficiency of each questionnaire in discriminating between patients with and without interstitial cystitis. RESULTS: Interstitial cystitis was distinguishable from the other diagnoses using both questionnaires (p <0.001). Separate analyses of bother and symptom scores yielded similar results. Receiver operating characteristic curves demonstrated the Pain, Urgency, Frequency Symptom Scale to be more efficient than the O'Leary-Sant Symptom Index and Problem Index in detecting interstitial cystitis in this population with an optimal cutoff value of 13 or greater. CONCLUSIONS: While the Pain, Urgency, Frequency Symptom Scale and the O'Leary-Sant Symptom Index and Problem Index questionnaires distinguish interstitial cystitis from other urinary tract pathologies, neither questionnaire demonstrates sufficient specificity to serve as the sole diagnostic indicator. These questionnaires should not be used to define interstitial cystitis, but can be used to screen patients with urinary tract symptoms to identify those who should be further examined for interstitial cystitis or to follow those who have already been diagnosed.

What Is a Clinician To Do-Believe the Patient or her Urinary Diary?
Kenton K, Fitzgerald MP, Brubaker L
J Urol. 2006 Aug;176(2):633-5.

PURPOSE: We determined if patient recall of incontinence episodes correlates with urinary diary record. MATERIALS AND METHODS: Women with 1 or more urge incontinence episode per week completed 2, 7-day diaries, the Urinary Distress Inventory and Incontinence Impact Questionnaire, and responded to 2 recall questions. RESULTS: The median number of incontinence episodes participants recalled (6.5, 5) was higher than those recorded in the diary (1.9, 1.1) at both points. Incontinence episodes in 2, 7-day diaries correlated strongly (rho = 0.921, p <0.005) while participant recall of incontinence episodes correlated weakly (rho = 0.309, p <0.059). When subjects reported being only slightly or not bothered by urge incontinence, recall and diary record correlated strongly (rho = 0.812, p = 0.014). With increasing bother (moderate or great), recall and diary were not significantly correlated (rho = 0.528, p = 0.115). CONCLUSIONS: Women with urge incontinence either overestimate or under record incontinence episode frequency in the urinary diary. This effect is more pronounced in women who are more bothered by incontinence.

Determining the importance of change in the overactive bladder questionnaire.
Coyne KS, Matza LS, Thompson CL, Kopp ZS, Khullar V
J Urol. 2006 Aug;176(2):627-32.

PURPOSE: The overactive bladder questionnaire assesses symptom bother and health related quality of life in patients with overactive bladder. It has been shown to be reliable, valid and responsive. We established the minimally important difference of the overactive bladder questionnaire. MATERIALS AND METHODS: Post hoc analyses from 2 clinical trials were performed. Distribution based, eg effect size, and anchor based analyses using perception of treatment benefit and clinical variables were used. RESULTS: The mean age of the 2 study populations was 58.8 and 58.7 years, respectively. Patients were predominantly female (51.8% and 75.1%) and white (83.9% and 87%, respectively). Half SD of the overactive bladder questionnaire symptom bother subscale was 9.1 to 9.3, and half SD of the overactive bladder questionnaire health related quality of life subscales (coping, concern, sleep and social interaction) was 9.8 to 13.2. Questionnaire subscales had moderate to large effect sizes with the largest effect sizes for symptom bother (-0.85 to -1.09). Anchor based analyses showed that significantly greater change scores were associated with greater patient perceived treatment benefit and satisfaction. The difference between change scores in patients perceiving no and little benefit was 7.4 to 16.5 for all questionnaire scales except social interaction with the majority greater than 10 points. Greater change scores were consistently associated with greater improvements in micturition diary variables. CONCLUSIONS: Multiple methodologies provide strong justification for the recommendation of a 10-point minimally important difference for all overactive bladder questionnaire subscales. This minimally important difference may be conservative for some subscales, although a uniform minimally important difference is recommended to facilitate interpretation of the overactive bladder questionnaire.
Editorial comment. Brubaker L. J Urol. 2006 Aug;176(2):632.

Visual analog scale questionnaire to assess quality of life specific to each symptom of the international prostate symptom score.
Ushijima S, Ukimura O, Okihara K, Mizutani Y, Kawauchi A, Miki T
J Urol. 2006 Aug;176(2):665-71.

PURPOSE: We assessed patient quality of life specific to each of the 7 items on the International Prostate Symptom Score, as evaluated with a novel visual analog scale questionnaire. MATERIALS AND METHODS: A total of 246 male patients with a chief complaint of lower urinary tract symptom were asked to complete the International Prostate Symptom Score and visual analog scale questionnaires to assess bother or satisfaction regarding patient quality of life specific to each of the 7 items on the International Prostate Symptom Score. RESULTS: An item with the maximum visual analog scale measure matched the chief complaint in 169 patients (69%). In contrast, the chief complaint failed to match to an item with the most severe International Prostate Symptom Score in 104 patients (42%) (p = 0.012). Multiple regression analysis to define the best predictor of International Prostate Symptom Score quality of life score of the 14 items, including International Prostate Symptom Score and visual analog scale, revealed that the best predictor was the visual analog scale measure for nocturia (p = 0.0003), followed by visual analog scale measures for frequency (p = 0.0004) and incomplete emptying (p = 0.01). After alpha-blocker treatment improvement in the visual analog scale measure for the chief complaint correlated better with improvement in the International Prostate Symptom Score quality of life score than the change in International Prostate Symptom Score. The overall test-retest correlation for the visual analog scale questionnaire in 55 healthy elderly men and 44 patients with lower urinary tract symptoms was 0.772 and 0.742, respectively (p <0.00001). CONCLUSIONS: The novel visual analog scale measure of quality of life specific to each of the 7 items on the International Prostate Symptom Score has a significant impact on identifying the patient chief complaint as well as on patient specific quality of life. Our study supports the concomitant use of the International Prostate Symptom Score and visual analog scale questionnaires.


The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence.
Brown JS, Bradley CS, Subak LL, Richter HE, Kraus SR, Brubaker L, Lin F, Vittinghoff E, Grady D
Ann Intern Med. 2006 May 16;144(10):715-23.

BACKGROUND: Urinary incontinence is common in women. Because treatments differ, urge incontinence should be distinguished from stress incontinence. To make this distinction, current guidelines recommend an extensive evaluation that is too time-consuming for primary care practice. OBJECTIVE: To test the accuracy of a simple questionnaire to categorize type of urinary incontinence in women. DESIGN: Multicenter, prospective study of the accuracy of the 3 Incontinence Questions (3IQ) compared with an extended evaluation to distinguish between urge incontinence and stress incontinence. SETTING: 5 academic medical centers in the United States. PARTICIPANTS: 301 women enrolled from April to December 2004 who were older than 40 years of age (mean age, 56 years [SD, 11]) with untreated incontinence for an average of 7 years (SD, 7) and a broad range of incontinence severity. MEASUREMENTS: All participants included in the analyses answered the 3IQ questionnaire, and a urologist or urogynecologist who was blinded to the responses performed the extended evaluation. Sensitivity, specificity, and likelihood ratios were determined for the 3IQ. RESULTS: For classification of urge incontinence and with the extended evaluation as the gold standard, the 3IQ had a sensitivity of 0.75 (95% CI, 0.68 to 0.81), a specificity of 0.77 (CI, 0.69 to 0.84), and a positive likelihood ratio of 3.29 (CI, 2.39 to 4.51). For classification of stress incontinence, the sensitivity was 0.86 (CI, 0.79 to 0.90), the specificity was 0.60 (CI, 0.51 to 0.68), and the positive likelihood ratio was 2.13 (CI, 1.71 to 2.66). LIMITATIONS: Participants were enrolled by urologists and urogynecologists at academic medical centers. CONCLUSIONS: The 3IQ questionnaire is a simple, quick, and noninvasive test with acceptable accuracy for classifying urge and stress incontinence and may be appropriate for use in primary care settings. Similar studies are needed in other populations. We also need a clinical trial comparing the outcomes of treatments based on the 3IQ and the extended evaluation.

Italian Validation of the Urogenital Distress Inventory and Its Application in LUTS Patients.
Artibani W, Pesce F, Prezioso D, Scarpa RM, Zattoni F, Tubaro A, Rizzi CA, Santini AM, Simoni L
Eur Urol. 2006 May 4;.

OBJECTIVES: The objective of this study was to validate the Italian version of the Urogenital Distress Inventory (UDI) in a sample of women with lower urinary tract symptoms (LUTS). METHODS: The linguistic validation of the questionnaire was performed through a multistep process: backward and forward translations coordinated by clinical investigators, followed by a pretest. The final version was administered to a larger sample of female patients, aged 18 years or older who had been having LUTS for at least 3 months, numbering 53 subjects. To evaluate test-retest reliability, patients were re-rated after 1 week. To test questionnaire's capacity to discriminate women with or without LUTS (cases and controls, respectively), a sample of 53 healthy women was enrolled. A 72-h voiding diary was used as a gold standard and compared with the UDI. RESULTS: The correlation coefficient between ratings was >/=0.80, and the discriminant power between cases and controls was confirmed. The UDI showed good internal consistency for all domains, except irritative symptoms (total score's Cronbach alpha=0.86). Factor analytic structure revealed urinary incontinence to be opposite to the other urologic symptoms, with bed wetting being loaded separately. The average daily number of urgent micturitions was higher in patients who reported they "experience a strong feeling of urgency to empty bladder" in the UDI than those ones who did not (p<0.01). CONCLUSIONS: The Italian version of the UDI is a valid and robust instrument, which can now be used reliably in daily practice and clinical research.

Re: A Nomogram to Classify Men With Lower Urinary Tract Symptoms Using Urine Flow and Noninvasive Measurement of Bladder Pressure
C. J. Griffiths, C. Harding, C. Blake, S. McIntosh, M. J. Drinnan, W. A. Robson, P. Abrams, P. D. Ramsden and R. S. Pickard J Wang SJ, Lin AT
J Urol. 2006 Jul;176(1):411.

Reply by authors.

J Urol. 2006 Jul;176(1):411.

Value of leak point pressure study in women with incontinence.
Sinha D, Nallaswamy V, Arunkalaivanan AS
J Urol. 2006 Jul;176(1):186-8.

PURPOSE: We assessed the relationship between cough leak point pressure and Valsalva leak point pressure with stress incontinence and detrusor overactivity. MATERIALS AND METHODS: This prospective study was performed on 109 women with urinary incontinence who underwent urodynamic assessment from December 2003 to June 2005. We recorded cough leak point pressure and Valsalva leak point pressure by asking the patient to cough and to perform a Valsalva maneuver at maximum cystometric capacity until urine loss was directly observed and recorded by the machine. Women with normal urodynamic results or spontaneous voiding during examination were excluded fro analysis. Results were entered in the urodynamic database and analyzed using SPSS(R) release 13.0. RESULTS: Of the 109 women in the study 61 (56%) had stress incontinence, 21 (19%) had detrusor overactivity and 27 (25%) had mixed incontinence. All women with stress incontinence demonstrated leak at cough leak point pressure but 40 women (66%) did not leak with the Valsalva maneuver. Of the 21 patients who had detrusor overactivity 16 (76%) did not leak at cough leak point pressure whereas 17 (81%) leaked with the Valsalva maneuver. In the group of 27 women with mixed incontinence all leaked with cough at cough leak point pressure but only 17 (63%) leaked with the Valsalva maneuver. CONCLUSIONS: Women with stress incontinence diagnosed with urodynamics leaked more at cough leak point pressure than the Valsalva maneuver, and women with detrusor overactivity leaked less at cough leak point pressure and more with the Valsalva maneuver.


Prophylactic antibiotics after urodynamics in women: a decision analysis.
Lowder JL, Burrows LJ, Howden NL, Weber AM
Int Urogynecol J Pelvic Floor Dysfunct. 2006 May 4;.

The objective of this paper is to compare the risks and benefits of antibiotics to prevent urinary tract infection (UTI) after urodynamics. We developed a decision analytic model to compare the use of prophylactic antibiotics with no antibiotic use after urodynamics to prevent UTI. Risks and benefits were estimated from the literature and by consensus. The main outcome measure was the occurrence of UTI. Secondary outcomes were the development of adverse events and possible sequelae. One-way sensitivity analyses estimated the effect of varying each characteristic through its range while all other characteristics were fixed at their baseline values. The effectiveness of prophylaxis after urodynamics was a reduction of UTI from 9.2 (no antibiotics) to 5.3% (antibiotics). One-way sensitivity analysis of the probability of UTI without prophylaxis yielded a threshold infection rate of 10%, below which, the strategy of no prophylaxis was favored. In this model, prophylactic antibiotics after urodynamics are not beneficial until the rate of UTI without antibiotics exceeds 10%.3 Urology 2006 03

The reproducibility of urodynamic finding in health female volunteers: results of repeated studies in the same setting and after short-term follow-up.
Wein AJ
J Urol. 2004 Dec;172(6 Pt 1):2493-4.

A shifted paradigm for the further understanding, evaluation, and treatment of lower urinary tract symptoms in men: focus on the bladder.
Chapple CR, Roehrborn CG

Lower urinary tract symptoms (LUTS) are highly prevalent among older men and have a negative impact on health-related quality of life. Frequent comorbidity with potential prostatic disease adds complexity to the management of male LUTS. In this review, we discuss the pathophysiological conditions that underlie male LUTS, and examine the relationship between symptoms and urodynamic findings. The contribution of bladder dysfunction to male LUTS, with a particular emphasis on overactive bladder (OAB) symptoms, is explored. We also consider pharmacotherapeutic options for male LUTS. Pharmacotherapies that target the prostate (alpha(1)-receptor antagonists and 5alpha-reductase inhibitors) often fail to alleviate OAB symptoms, and may not be the most appropriate therapy for men with storage LUTS. Multiple studies have suggested that antimuscarinic therapy alone or in combination with alpha(1)-receptor antagonists improve OAB symptoms in men with and without bladder outlet obstruction. Although these agents may represent appropriate first-line therapies for men with OAB symptoms, the therapeutic potential of antimuscarinics alone or in combination with alpha(1)-receptor antagonists in this population should be evaluated in large-scale, well-designed clinical trials.


Valsalva leak point pressure to determine internal sphincter deficiency in stress urinary incontinence.
Rodrigues P, Afonso Y, Hering FO, Campagnari JC, Azoubel A
Urol Int. 2006;76(2):154-8.

INTRODUCTION: Valsalva leak point pressure (VLPP) represents the global competence of the conjunctive forces around the urethra to support increased pressure from the abdominal cavity with transmission to the bladder. Assessment of VLPP has prognostic meaning, but measurement techniques are still subject to controversy. PATIENTS AND METHODS: One hundred and eight consecutive women with no genital prolapse or bladder hyperactivity exclusively presenting with urinary stress incontinence were submitted to VLPP determination during urodynamic evaluation using a rectal and urethral catheter. Rectal pressure measurement served as the landmark in the determination of Valsalva's maneuver. After determining the rectal pressure, the urethral probe was pulled out and the maneuver repeated. RESULTS: Eighty-four cases (group I) presented leakage during Valsalva's maneuver with the urethral catheter being in place. Group Ia (66.6%) had a reduction of 44.5 cm H(2)O in the rectal pressure after catheter removal. In group Ib, rectal leakage pressure increased after catheter removal from 76.5 +/- 18.7 to 79.5 +/- 24.7 cm H(2)O. Eight patients did not demonstrate urine leakage after catheter removal. In group II, 24 cases showed a rise in rectal leakage pressure to 76.2 +/- 22 cm H(2)O, but urinary leakage was only observed after catheter removal. In group IIa (19 cases), the VLPP decreased by 12.6 +/- 15 cm H(2)O, while in group IIb (5 cases) leakage occurred only in patients showing an increase of 22.2 +/- 7 cm H(2)O in the rectal pressure after the second maneuver with the urethral catheter in position. CONCLUSIONS: Precise determination of the abdominal leak point pressure through Valsalva's maneuver may be critical. The different techniques used for VLPP determination may render comparisons difficult. Rectal pressure measurement with no urethral catheter in place to monitor abdominal leak pressure seems to be more appropriate because it resembles clinical practice. Although lower abdominal leakage pressures may be found, this is not a uniform finding, and a higher incidence of type III incontinence may be expected, and critical analysis or painstaking repetition may be required in the case of lack of demonstration of urinary loss.

The Association Between Vascular Risk Factors and Lower Urinary Tract Symptoms in Both Sexes.
Ponholzer A, Temml C, Wehrberger C, Marszalek M, Madersbacher S
Eur Urol. 2006 Feb 17;.

OBJECTIVES: To test the potential role of atherosclerosis in the development of lower urinary tract symptoms (LUTS), we investigated the association between vascular risk factors and LUTS in both sexes. METHODS: Men and women participating in a health screening project completed the International Prostate Symptom Score (IPSS). In parallel all individuals underwent a detailed health investigation with assessment of diabetes mellitus, hypertension, hyperlipidemia, and nicotine use. RESULTS: A total of 1724 men (52.3+/-9.1yr, mean+/-standard deviation; IPSS: 6.3+/-4.3) and 812 women (56.0+/-9.9 yr; IPSS: 5.2+/-4.9) entered the study. A total of 62.5% (n=1077) of men had no vascular risk factor, 32.1% (n=554) one, and 5.4% (n=93) two or more; the corresponding figures for women were 64.7% (n=525), 30.7% (n=249), and 4.7% (n=38). In men, the IPSS was identical in those with no (6.2+/-4.1) and one (6.2+/-4.4) vascular risk factor yet increased to 7.7+/-5.5 (+24.2%) in those with two or more risk factors (p=0.01). In women, the IPSS increased from 4.8+/-4.6 in those with no vascular risk factor to 5.7+/-5.3 (+18.7%) with one and 7.0+/-5.7 (+45.8%) with two or more factors (p=0.05). CONCLUSIONS: Our data suggest that vascular risk factors play a role in the development of LUTS in both sexes. This observation opens new aspects in our understanding of the pathogenesis of LUTS and warrants future studies.


Is nocturia equally common among men and women? A population based study in Finland.
Tikkinen KA, Tammela TL, Huhtala H, Auvinen A
J Urol. 2006 Feb;175(2):596-600.

PURPOSE: We assessed the prevalence of nocturia and its association with sociodemographic factors. MATERIALS AND METHODS: Information was collected with a questionnaire mailed to a random sample of 6,000 subjects 18 to 79 years old, identified from the Finnish Population Register Centre. Nocturia was defined as 1 or more, or 2 or more voids per night. Information was collected using the DAN-PSS questionnaire with an additional question from the AUA-SI questionnaire. Age standardized prevalence was calculated using the European standard population. Logistic regression was used for multivariate analysis. RESULTS: Of the 6,000 subjects 62.4% responded and 97.9% of the participants provided information on all nocturia questions. The age standardized prevalence of nocturia (1 or more voids per night) was 37% (95% CI 34%-40%) among men and 43% (95% CI 40%-46%) among women. With criterion of 2 or more voids per night prevalence was 12% (95% CI 10%-14%) for men and 13% (95% CI 11%-14%) for women. Women 18 to 49 years old had more nocturia than men. At 50 to 59 years old half of men and women reported nocturia. In older age groups nocturia was more frequent among men than women. The prevalence of nocturia increased at a constant rate with age. It increased twice as rapidly in men as among women (increase in OR 7.3% [95% CI 6.5%-8.2%] and 3.5% [95% CI 2.9%-4.1%] per year among men and women, respectively). CONCLUSIONS: The age standardized prevalence of nocturia (1 or more voids per night) was approximately 40% for both genders. In men the prevalence of nocturia increases more rapidly with age than in women. Nocturia is more common among women at a younger age but the differences disappear by middle age. In the elderly nocturia is more frequent among men.

Current trends in lower urinary tract health highlights from annual advances in genitourinary health: a scientific update.
Blaivas JG, Burnett AL, Wein AJ
J Urol. 2006 Mar;175(3 Suppl):S3-4.

The aging lower urinary tract.
Dubeau CE
J Urol. 2006 Mar;175(3 Suppl):S11-5.

PURPOSE: Age related changes in continence and the GU system, and how they affect the management of LUT dysfunction are discussed. Guidelines are offered regarding the diagnosis and management of incontinence in the elderly population. MATERIALS AND METHODS: Published literature and current treatment practice specific to elderly patients with LUT dysfunction were reviewed. RESULTS: LUT symptoms in the elderly population are affected by the high prevalence of comorbidity and polypharmacy. In addition, the GU system undergoes age related changes that increase the risk of LUT dysfunction. CONCLUSIONS: Incontinence in older persons is almost always caused by multiple factors, of which not all are directly related to the GU system. Issues such as polypharmacy, comorbidity, and the increased risk of medication side effects must be considered in planning treatment. The primary care physician and urologist or gynecologist should establish a partnership to co-manage the broad spectrum of factors affecting continence in elderly patients.

Maximal urethral closure pressure < 20 cm H2O: does it predict intrinsic sphincteric deficiency?
Krissi H, Pansky M, Halperin R, Langer R
J Reprod Med. 2005 Nov;50(11):824-6.

OBJECTIVE: To assess whether the large discrepancy in the literature in the incidence of intrinsic sphincteric deficiency (ISD) is due to different methods by which maximal urethral closure pressure (MUCP) is measured. STUDY DESIGN: We compared the measurement of MUCP in the supine position with 300 mL saline in the bladder, according to International Continence Society guidelines, to that in the sitting position (full bladder) in 54 consecutive patients who were diagnosed as having stress urinary incontinence. RESULTS: In the supine position the mean MUCP was 38.4 +/- 2.85 cm H2O as compared to 22.80 +/- 3.22 cm H2O in the sitting position (p < 0.0001). The mean difference was 15.65 +/- 2.11 cm H2O. MUCP < or = 20 cm H2O was observed in 14 of 54 (25.9%) patients in the sitting position as compared to 1 of 54 (1.8%) in the supine position. CONCLUSION: When MUCP is measured in the supine position, according to International Continence Society guidelines, the cutoff point for diagnosis of ISD should be 35 rather than 20 cm H2O.

Investigation of dysfunctional voiding in children with urgency frequency syndrome and urinary incontinence.
Kuo HC, Liu HT
Urol Int. 2006;76(1):72-6.

PURPOSES: Dysfunctional voiding may result in lower urinary tract symptoms (LUTS) in children and is associated with urinary tract infection and vesicoureteral reflux (VUR). This study analyzed the videourodynamic investigations in children with urgency frequency syndrome and/or urinary incontinence. METHODS: Forty children, 1-13 years old, with urgency frequency syndrome and/or incontinence were investigated to determine their LUTS or for the assessment of VUR. Videourodynamic study was performed in all patients and the results were analyzed with clinical characteristics and underlying pathophysiology. RESULTS: Dysfunctional voiding was present in 75.7% of the children with detrusor overactivity, in 73.3% of the children with VUR, in 63% of the children with urinary incontinence, in 77% of the children with episodic urinary tract infection, and in all of the children with diurnal enuresis. Compared to children without dysfunctional voiding, the voiding pressure was significantly higher in children with dysfunctional voiding (with VUR, 61.1 +/- 29.8 vs. 24.8 +/- 15.8 cm H(2)O, p = 0.004; without VUR, 53.4 +/- 24.1 vs. 24.8 +/- 15.8 cm H(2)O, p = 0.010). Biofeedback pelvic floor muscle training and treatment with antimuscarinic agent effectively decreased detrusor pressure, increased bladder capacity and maximum flow rate, and reduced the grade of VUR in 5 children who had post-treatment urodynamic studies. CONCLUSIONS: This study has shown that dysfunctional voiding is highly prevalent in children with symptoms of urgency frequency and incontinence. Biofeedback pelvic floor muscle training is effective in treatment of dysfunctional voiding in children.

Perineal ultrasound evaluation of the urethrovesical junction angle and urethral mobility in nulliparous women and women following vaginal delivery.
Costantini S, Nadalini C, Esposito F, Valenzano MM, Risso D, Lantieri P, Mistrangelo E
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Nov-Dec;16(6):455-9. Epub 2005 Jul 26.

The objective of this study was to demonstrate the differences in the urethrovesical junction angle and urethral mobility by means of perineal ultrasounds in women following vaginal delivery with respect to nulliparous women. We have enrolled 34 women, 12 nulliparous (Group A) and 22 women in the post-partum period (Group B). The ultrasounds were employed to measure the urethrovesical junction angle ("urethro-pelvic" angle) and the urethral mobility. Data obtained show that the urethro-pelvic angle is narrower in Group A (97.3 degrees) with respect to Group B (112.5 degrees). Urethral mobility while coughing was significantly higher in Group B (30.4 degrees) with respect to Group A (-2 degrees). This study demonstrates the difference in the urethral support at rest and during cough in nulliparous versus recently delivered parous women.

Usefulness of urine dipstick in an urogynecologic population.
Raza-Khan F, Kenton K, Shott S, Brubaker L
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan 12;:1-3.

Urine dipstick alone is insufficient for diagnosing urinary tract infection in patients with pelvic floor disorders.

Factors affecting health-related quality of life among patients with lower urinary tract symptoms.
Quek KF
Int J Urol. 2005 Dec;12(12):1032-6.

BACKGROUND: This study aimed to evaluate the association of factors such as pain, lower urinary tract symptoms (LUTS), anxiety, depression and psychiatric morbidity on health-related quality of life (HRQoL) of patients with LUTS. METHODS: A total of 227 patients with LUTS were recruited into the study. The patients were assessed on pain, LUTS, anxiety, depression, psychiatric morbidity and health-related quality of life (HRQoL) using standardized questionnaires. RESULTS: The study showed that after adjustment, age, pain, anxiety, depression, psychiatric morbidity and LUTS contributed 31%, 13%, 45%, 16% and 48% respectively to the variability of the physical, mental, social, global and overall HRQoL. CONCLUSION: Age, pain, psychiatric morbidity, anxiety and depression are associated with HRQoL among patients with LUTS.

The PSA Conundrum.
Barry MJ
Arch Intern Med. 2006 Jan 9;166(1):7-8.