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Clinical Evaluation of Bladder Pressure Studies in Urological Patients by Combined Cystometry and Uroflometry
Vol. 95, .June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright@ 1966 by The Williams & Wilkins Co.
CLINICAL EVALUATION OF BLADDER PRESSURE STUDIES IN UROLOGICAL PATIENTS BY COl\IBIKED CYSTOMETRY AND UROFLOMETRY SAUL BOYARSKY, PEREGRINA LABAY, ARNOLD KRUGMAN, JAMES F. GLENN AKD TIN A NEWMARK
From the Urology Service ancl Division of Urnlogy, Department of Surgery, Diike University Medical Genier, Durham Yeterans Administration Hospital, Durham, }forth Camlina
Clinical function tests are always a compromise between simplicity and complexity. The cystometrograrn. in its various phases of development as a bladder function test has been buffeted by these opposing demands. Recently it has undergone considerable evolution secondary to progress in bladder physiology. The tracing of bladder pressure alone is an incomplete datum since urethral resistance, detrusor decompensation and other influences are not known. Direct cystometry, i.e. pressure measurement through percutaneous suprapubic tubing during the act of micturition, has shown pressure values to be lower than the values obtained by older techniques. Uroflometry represents the quantitation of the observation of the act of micturition, long a valuable part of the urologic examination.1-9 Accepted for publication July 23, 1965. Supported in part by the Vocational Rehabilitation Administration, grant RD1358M and grants from the Mary Duke Biddle Foundation. Presented at annual meeting of Southeastern Section, American Urological Association, Inc., Miami Beach, Florida, March 14-18, 1965. 1 Murphy, J. J. and Schoenberg, H. W.: Direct cystometry: An approach to the study of the hydrodynamics of the lower urinary tract. Brit. J. Urol., 34: 318-321, 1962. 2 von Garrelts, B.: Analysis of micturition. Acta Chir. Scand., 112: 326, 1957. 3 Ritter, R. C., Zinner, N. R. and Paquin, A. J., Jr.: Clinical urodynamics. II. Analysis of pressure-flow relations in the normal female urethra. J. Urol., 91: 161-165, 1964. 4 Scott, F. B., Quesada, E. JVI. and Cardus, D.: Studies on the dynamics of micturition: Observations on healthy men. J. Urol., 92: 455-463, 1964. 5 Pierce, J. M., Jr., Brann, E., Sniderman, A. J. and Lewis, H. Y.: The concept of resistance to flow applied to the lower urinary tract. Surg., Gynec. & Obst., 116: 217-222, 1963. 6 Claridge, M. and Shuttleworth, K. E. D.: The dynamics of obstructed micturition. Invest. Urol., 2: 188-199, 1964. 7 King, L. R., Mellens, H. Z. and White, H.: Measurement of the intravesical pressure during voiding: An analysis of pressure recordings made by three different techniques with comment on the diagnostic significance of such studies in the evaluation of bladder outflow obstruction. Invest. Urol., 2: 303-322, 1965. 778
1. Comparisons of re.rnlts of different tests macle on the same patient prior to therapy
TABLE
Bladder Capacity
1viaximum Pressure
Flow rate
(cm. H20)
(ml./sec.)
Resistance
Residual Urine
J. S.: Preoperative benign proslatic hypertrophy;
retropubic prostatectomy. 380 64 1. 7 22.4 320 320 27 4.3 1. 5 105 320 4.5 60 3.0 200 H. G.: Preoperative prostatic carcinoma; radical perineal prostateclomy. 240 120 3.6 9.3 100 250 162 2.7 22.2 90 250 181 3.9 11.9 140 R. G.: Prostatitis, unproven blaclcler hypotonia secondary to olcl hernia/eel inlervertebral clisk. 700 54 6. 9 1 .13 125 68 7. 6 1.18 150 700 J. R. M.: Papilloma of blaclcler; later, acute urinary retention; transurethral resection. 250 142 2. 2 29.0 50 250 142 2.8 32.0 15 D. J.: Quadriplegic 7/15/64 150 52 3.5 5.0 150 62 3.5 5.9 275 7/21/64 210 19 5 0.8 180 (Pudendal block performed and test repeated) 210 5 19 0.8 180 (Intravesical pressure already elevated to 110 cm. H20 before voiding)
METHOD
In our studies we used combined direct cystometry and simultaneous uroflometry. Recording was continuous from the commencement of 8 Kaufman, J. J.: A new recording uroflometer: A simple automatic device for measuring voiding velocity. J. Urol., 78: 97-102, 1957. 9 Drake, W. M., Jr.: The uroflometer in the study of bladder neck obstructions. J .A.M.A., 156: 1079, 1954.
t
r
779
CLINICAL EVALUATION OF BLADDER PRESSURE STUDIES TABLE
2. Clinical correlation of test in 19 cases
Patient
E.P. H.G. R.D. R. S. J. s. B. 0.
J. R.M. H.T. E. s. J.B.
B. T. T. L. R. S. (pediatric) T. J. (pediatric)
W.L. J. R. C. L. C. P. (female) C. G. (female)
Diagnosis
Preop. BPH* Preop. prostatic carcinoma Preop. BPH Preop. BPH Preop. BPH Preop. BPH Bladder tumor, later required TUR for BPH Preop. BPH Preop. BPH Preop. BPH Preop. BPH Preop. BPH Spastic paraplegic Vesical neck contracture Early BPH, no therapy needed Possible early BPH, no therapy needed Possible early BPH, no therapy needed Recurrent infection, no obstruction Recurrent infection, no obstruction, megacystis?
Resistance
20.5 9.0, 22.0 5.3 5.3 1.5, 3.0 3.7, 4.6 29, 32 31.4 6.9 5.7 5.0, 7.4 12.8 1.7-6.8 (anesth) 15.0 (anesth) 0.55 0.07 0.18 0.15 0.08
* BPH-benign prostatic hypertrophy. TABLE
Patient
R.A. A. S.* J. A. McM. H. McD.* J. W. L.* L. J. T.W. W.M. J. T.* W.R. C.* R.H.* T. T. J. R. T.B. J.E.W. F. S.* H.O. C. P.*
3. Effect of therapy on urethral resistance Procedure
Preop. to Postop.
TUR for BPHt TUR for BPH TUR for BPH TUR for BPH TUR for BPH TUR for BPH TUR for BPH Rad. perineal prostatectomy TUR for BPH, early TUR for BPH-good result TUR for BPH TUR for BPH TUR for BPH TUR for BPH and dilatation of urethral stricture TUR for BPH TUR for BPH Urethral dilatation Postop TUR for BPH
1.6 to 0.83 2.7 to 12.5 22.0 to 0.32 3.0 to 36.5 poor test to 6.6 retention to 0.73 2.2 to 1.3 5. 3 to 1. 1 and 2. 0 0.46 to 0.68 6.25 to 12 poor test to 28. 5 30 tounable to 1.8 no test 0.39 retention to 1. 6 0.39 to 0.13 unable to 5.1 no test to 4.8
* Cases considered diagnostic failures. Reversion of resistance to normal is not necessary. t TUR for BPH-transurethral resection for benign prostatic hypertrophy.
bladder filling to the start of micturition. Resistance was calculated from the mean pressure and flow by the formula proposed by Pierce and associates. 5 For this determination normal values are less than 0.4 for the urethral resistance and more than 15 cc per second for flow rate.
A total of 110 studies was made in 60 unselected patients who had suspected or actual bladder obstruction. Our ultimate goal was to standardize the test for diagnostic purposes in patients with neurogenic bladder as well as those with obstruction. The test is a combined direct cystometric
780
BOYARSKY AND ASSOCIATES
4. Urine flow rates in milliliters per second; results of tests made in patient's room compared to resiills of normal testing
TABLE
Patient
Pre-test
Test
T. B. B. T. W.M. J.W. W.J. F. S.-preop postop
13.3 5.0 22.5
15.0 7.4 11. 7 0
0
0
1.6
1.6
5.4 2.8
3.3
study with simultaneous uroflometry which requires suprapubic puncture and cannulation with fine polyethylene tubing. The pressure is recorded throughout the filling phase as it is in the conventional cystometrogram and continuously throughout micturition. The flow rate is recorded sinrnltaneously. Transducer and electronic recorders are used; however, a stopwatch, urinal and a meter stick and upright water-filled tubing have been used, although with less convenience. The test has been done by all members of our service. There have been no significant sequelae. We attribute this to a rigid order that the test must not be performed on any patient unless his bladder can be distended and palpated suprapubically. The results of successive tests in the same patients are shown in table 1. In J. S. the bladder was filled to more than 300 cc and the resistance values were noted to be abnormal. The first result of 22.4 was discounted possibly because the patient was not yet familiar with the test. In H. G. the results were consistent but the values were extremely high. In the third and fourth patients much better correspondence was noted and was attributed to our experience in performing the test. The urethral resistance proved to be a significant datum. A general good correlation with the complete clinical picture was observed. The test results were quite reasonable in most of the patients. Significant vesical neck obstruction was noted clinically in the first 14 patients and urethral resistance was elevated to values between 1.5 to 32. In the last 5 patients no clinical obstruction was demonstrated and the urethral resistance was within normal limits except W. L. who was on the borderline (table 2).
Preoperative and postoperative studies were made in 18 patients subjected to transurethral resection, open prostatectomy or urethral dilatation. Improvement was noted in 10 of the 18 cases (table 3). In general, the result of therapy does not provide a completely solid basis for evaluation of this test. Some patients do not void freely for several days following a prostatic operation due to transitory inflan1mation, spasm. and edema. This test will never be a panacea; not every patient is a candidate. There were 21 test failures in 18 patients. These failures were classified as a technical error in 1 case, difficulty in puncture in 2 cases and inability to void in 18 cases (1 patient was mentally incompetent, 8 patients were probably completely obstructed, 3 patients were weak or had neurologic disease and 3 patients, 6 tests, had psychological complications). To determine the degree of interference with urine flow because of test conditions, flow rates were determined in 6 patients in their room. In each case the flow rate remained in the same range whether the patient was alone in his room or undergoing regular test. Patient W. M. showed 22.5 cc per second in his roon1. and 11.7 cc per second during the test; the others showed closer correspondence (table 4). SUMMARY
The combined direct cystometric and uroflometric study is far superior to the conventional cystometrogram. It is physiologically sounder, sacrifices no information and allows calculation of urethral resistance in patients with early and late bladder neck obstruction. The test was hampered by psychologic inhibitions and technical obstacles in some cases but proved to be vastly more informative than the conventional cystometrogram. With simple precautions it has been safe in our hands. A definite advantage of this technique is the ability to record flow from the start of filling of the bladder to the completion of micturition. It also obviates the need for sphincterometry. In most cases, the results of the test were consistent with the degree of obstruction as judged by all other modalities of study. This test is still in the stage of clinical development and its final role has yet to be assessed on the basis of further experience.
THE JOURNAL OF UROLOGY
Copyright@ 1966 by The Williams & Wilkins Co.
CLINICAL EVALUATION OF BLADDER PRESSURE STUDIES IN UROLOGICAL PATIENTS BY COl\IBIKED CYSTOMETRY AND UROFLOMETRY SAUL BOYARSKY, PEREGRINA LABAY, ARNOLD KRUGMAN, JAMES F. GLENN AKD TIN A NEWMARK
From the Urology Service ancl Division of Urnlogy, Department of Surgery, Diike University Medical Genier, Durham Yeterans Administration Hospital, Durham, }forth Camlina
Clinical function tests are always a compromise between simplicity and complexity. The cystometrograrn. in its various phases of development as a bladder function test has been buffeted by these opposing demands. Recently it has undergone considerable evolution secondary to progress in bladder physiology. The tracing of bladder pressure alone is an incomplete datum since urethral resistance, detrusor decompensation and other influences are not known. Direct cystometry, i.e. pressure measurement through percutaneous suprapubic tubing during the act of micturition, has shown pressure values to be lower than the values obtained by older techniques. Uroflometry represents the quantitation of the observation of the act of micturition, long a valuable part of the urologic examination.1-9 Accepted for publication July 23, 1965. Supported in part by the Vocational Rehabilitation Administration, grant RD1358M and grants from the Mary Duke Biddle Foundation. Presented at annual meeting of Southeastern Section, American Urological Association, Inc., Miami Beach, Florida, March 14-18, 1965. 1 Murphy, J. J. and Schoenberg, H. W.: Direct cystometry: An approach to the study of the hydrodynamics of the lower urinary tract. Brit. J. Urol., 34: 318-321, 1962. 2 von Garrelts, B.: Analysis of micturition. Acta Chir. Scand., 112: 326, 1957. 3 Ritter, R. C., Zinner, N. R. and Paquin, A. J., Jr.: Clinical urodynamics. II. Analysis of pressure-flow relations in the normal female urethra. J. Urol., 91: 161-165, 1964. 4 Scott, F. B., Quesada, E. JVI. and Cardus, D.: Studies on the dynamics of micturition: Observations on healthy men. J. Urol., 92: 455-463, 1964. 5 Pierce, J. M., Jr., Brann, E., Sniderman, A. J. and Lewis, H. Y.: The concept of resistance to flow applied to the lower urinary tract. Surg., Gynec. & Obst., 116: 217-222, 1963. 6 Claridge, M. and Shuttleworth, K. E. D.: The dynamics of obstructed micturition. Invest. Urol., 2: 188-199, 1964. 7 King, L. R., Mellens, H. Z. and White, H.: Measurement of the intravesical pressure during voiding: An analysis of pressure recordings made by three different techniques with comment on the diagnostic significance of such studies in the evaluation of bladder outflow obstruction. Invest. Urol., 2: 303-322, 1965. 778
1. Comparisons of re.rnlts of different tests macle on the same patient prior to therapy
TABLE
Bladder Capacity
1viaximum Pressure
Flow rate
(cm. H20)
(ml./sec.)
Resistance
Residual Urine
J. S.: Preoperative benign proslatic hypertrophy;
retropubic prostatectomy. 380 64 1. 7 22.4 320 320 27 4.3 1. 5 105 320 4.5 60 3.0 200 H. G.: Preoperative prostatic carcinoma; radical perineal prostateclomy. 240 120 3.6 9.3 100 250 162 2.7 22.2 90 250 181 3.9 11.9 140 R. G.: Prostatitis, unproven blaclcler hypotonia secondary to olcl hernia/eel inlervertebral clisk. 700 54 6. 9 1 .13 125 68 7. 6 1.18 150 700 J. R. M.: Papilloma of blaclcler; later, acute urinary retention; transurethral resection. 250 142 2. 2 29.0 50 250 142 2.8 32.0 15 D. J.: Quadriplegic 7/15/64 150 52 3.5 5.0 150 62 3.5 5.9 275 7/21/64 210 19 5 0.8 180 (Pudendal block performed and test repeated) 210 5 19 0.8 180 (Intravesical pressure already elevated to 110 cm. H20 before voiding)
METHOD
In our studies we used combined direct cystometry and simultaneous uroflometry. Recording was continuous from the commencement of 8 Kaufman, J. J.: A new recording uroflometer: A simple automatic device for measuring voiding velocity. J. Urol., 78: 97-102, 1957. 9 Drake, W. M., Jr.: The uroflometer in the study of bladder neck obstructions. J .A.M.A., 156: 1079, 1954.
t
r
779
CLINICAL EVALUATION OF BLADDER PRESSURE STUDIES TABLE
2. Clinical correlation of test in 19 cases
Patient
E.P. H.G. R.D. R. S. J. s. B. 0.
J. R.M. H.T. E. s. J.B.
B. T. T. L. R. S. (pediatric) T. J. (pediatric)
W.L. J. R. C. L. C. P. (female) C. G. (female)
Diagnosis
Preop. BPH* Preop. prostatic carcinoma Preop. BPH Preop. BPH Preop. BPH Preop. BPH Bladder tumor, later required TUR for BPH Preop. BPH Preop. BPH Preop. BPH Preop. BPH Preop. BPH Spastic paraplegic Vesical neck contracture Early BPH, no therapy needed Possible early BPH, no therapy needed Possible early BPH, no therapy needed Recurrent infection, no obstruction Recurrent infection, no obstruction, megacystis?
Resistance
20.5 9.0, 22.0 5.3 5.3 1.5, 3.0 3.7, 4.6 29, 32 31.4 6.9 5.7 5.0, 7.4 12.8 1.7-6.8 (anesth) 15.0 (anesth) 0.55 0.07 0.18 0.15 0.08
* BPH-benign prostatic hypertrophy. TABLE
Patient
R.A. A. S.* J. A. McM. H. McD.* J. W. L.* L. J. T.W. W.M. J. T.* W.R. C.* R.H.* T. T. J. R. T.B. J.E.W. F. S.* H.O. C. P.*
3. Effect of therapy on urethral resistance Procedure
Preop. to Postop.
TUR for BPHt TUR for BPH TUR for BPH TUR for BPH TUR for BPH TUR for BPH TUR for BPH Rad. perineal prostatectomy TUR for BPH, early TUR for BPH-good result TUR for BPH TUR for BPH TUR for BPH TUR for BPH and dilatation of urethral stricture TUR for BPH TUR for BPH Urethral dilatation Postop TUR for BPH
1.6 to 0.83 2.7 to 12.5 22.0 to 0.32 3.0 to 36.5 poor test to 6.6 retention to 0.73 2.2 to 1.3 5. 3 to 1. 1 and 2. 0 0.46 to 0.68 6.25 to 12 poor test to 28. 5 30 tounable to 1.8 no test 0.39 retention to 1. 6 0.39 to 0.13 unable to 5.1 no test to 4.8
* Cases considered diagnostic failures. Reversion of resistance to normal is not necessary. t TUR for BPH-transurethral resection for benign prostatic hypertrophy.
bladder filling to the start of micturition. Resistance was calculated from the mean pressure and flow by the formula proposed by Pierce and associates. 5 For this determination normal values are less than 0.4 for the urethral resistance and more than 15 cc per second for flow rate.
A total of 110 studies was made in 60 unselected patients who had suspected or actual bladder obstruction. Our ultimate goal was to standardize the test for diagnostic purposes in patients with neurogenic bladder as well as those with obstruction. The test is a combined direct cystometric
780
BOYARSKY AND ASSOCIATES
4. Urine flow rates in milliliters per second; results of tests made in patient's room compared to resiills of normal testing
TABLE
Patient
Pre-test
Test
T. B. B. T. W.M. J.W. W.J. F. S.-preop postop
13.3 5.0 22.5
15.0 7.4 11. 7 0
0
0
1.6
1.6
5.4 2.8
3.3
study with simultaneous uroflometry which requires suprapubic puncture and cannulation with fine polyethylene tubing. The pressure is recorded throughout the filling phase as it is in the conventional cystometrogram and continuously throughout micturition. The flow rate is recorded sinrnltaneously. Transducer and electronic recorders are used; however, a stopwatch, urinal and a meter stick and upright water-filled tubing have been used, although with less convenience. The test has been done by all members of our service. There have been no significant sequelae. We attribute this to a rigid order that the test must not be performed on any patient unless his bladder can be distended and palpated suprapubically. The results of successive tests in the same patients are shown in table 1. In J. S. the bladder was filled to more than 300 cc and the resistance values were noted to be abnormal. The first result of 22.4 was discounted possibly because the patient was not yet familiar with the test. In H. G. the results were consistent but the values were extremely high. In the third and fourth patients much better correspondence was noted and was attributed to our experience in performing the test. The urethral resistance proved to be a significant datum. A general good correlation with the complete clinical picture was observed. The test results were quite reasonable in most of the patients. Significant vesical neck obstruction was noted clinically in the first 14 patients and urethral resistance was elevated to values between 1.5 to 32. In the last 5 patients no clinical obstruction was demonstrated and the urethral resistance was within normal limits except W. L. who was on the borderline (table 2).
Preoperative and postoperative studies were made in 18 patients subjected to transurethral resection, open prostatectomy or urethral dilatation. Improvement was noted in 10 of the 18 cases (table 3). In general, the result of therapy does not provide a completely solid basis for evaluation of this test. Some patients do not void freely for several days following a prostatic operation due to transitory inflan1mation, spasm. and edema. This test will never be a panacea; not every patient is a candidate. There were 21 test failures in 18 patients. These failures were classified as a technical error in 1 case, difficulty in puncture in 2 cases and inability to void in 18 cases (1 patient was mentally incompetent, 8 patients were probably completely obstructed, 3 patients were weak or had neurologic disease and 3 patients, 6 tests, had psychological complications). To determine the degree of interference with urine flow because of test conditions, flow rates were determined in 6 patients in their room. In each case the flow rate remained in the same range whether the patient was alone in his room or undergoing regular test. Patient W. M. showed 22.5 cc per second in his roon1. and 11.7 cc per second during the test; the others showed closer correspondence (table 4). SUMMARY
The combined direct cystometric and uroflometric study is far superior to the conventional cystometrogram. It is physiologically sounder, sacrifices no information and allows calculation of urethral resistance in patients with early and late bladder neck obstruction. The test was hampered by psychologic inhibitions and technical obstacles in some cases but proved to be vastly more informative than the conventional cystometrogram. With simple precautions it has been safe in our hands. A definite advantage of this technique is the ability to record flow from the start of filling of the bladder to the completion of micturition. It also obviates the need for sphincterometry. In most cases, the results of the test were consistent with the degree of obstruction as judged by all other modalities of study. This test is still in the stage of clinical development and its final role has yet to be assessed on the basis of further experience.