- Email: [email protected]
Proposed Cutoff Values to Define Bladder Outlet Obstruction in Women
VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY
Editorial Comment: Okada et a1 discuss the use of propiverine hydrochloride, a synthetic musculotropic antispasmodic agent, and the treatment of urge and stress incontinence. There were minimal side effects and no controls in their study. Although the results are suggestively promising, double-blind control studies are obviously necessary. Vaidyananthan et al describe the significant increase in the quality of life of spinal cord injured patients who are able to manage with intermittent catheterization plus pharmacological therapy to inhibit bladder contractility. Abrams et a1 reveal a promising new advance in pharmacological therapy for patients with overactive bladder. They describe tolterodine as a new antimuscarinic agent with affinity and specificity for muscarinic receptors in the bladder equal to oxybutynin but with 8 times less affinity for muscarinic receptors in the salivary gland. Alan J. Wein, M.D. Long-Tern Results and Complications of Augmentation Ileocystoplasty for Idiopathic Urge Incontinence in Women
S. A. AWAD,H. M. AL-ZAHRANI,J. B. GAJEWSKIAND A. A. BOURQUE-KEHOE, Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada Brit. J. Urol., 81: 569-573, 1998 Objective To assess the long-term (3-9 years) results of augmentation ileocystoplasty for nonneurogenic female urge incontinence in terms of continence, the need for intermittent self-catheterization and the need for additional or auxiliary treatment, to define the long-term complications and to assess the patients’ satisfaction with the outcome. Patients and methods The study comprised 51 women who underwent augmentation ileocystoplasty for non-neurogenic urge incontinence between November 1987 and December 1993; 27 patients had associated interstitial cystitis. All patients had exhausted conservative methods, with a n unsatisfactory outcome. All patients were interviewed about the results of the procedure, and their charts reviewed and updated with relevant information. Results Within a mean (range) follow-up of 75.4 (36-109) months, 27 patients (53%)were completely continent, 13 (25%) had occasional leaks and nine (18%) continued to have disabling urge incontinence frequently requiring pads. Regular self-catheterization was needed by 20 (39%) patients while the rest emptied adequately with no or minimal residual volumes. Additional pharmacotherapy had to be used by 12 (24%) patients. Three patients later developed stress urinary incontinence and were managed with fascia1 sling procedures. The patch was revised in two patients and excised from four others because they had high residual volumes and uncontrollable infections. Two patients had an ileal conduit diversion for persistent incontinence. The most common complication was recurrent urinary tract infections, seen in 22 patients using intermittent self-catheterization. Mucus retention occurred regularly in 10 patients, six had chronic diarrhoea, four had latent bowel obstruction, one developed a bladder stone, one a n incisional hernia and one developed patch necrosis and perforation. Twenty-seven patients (539) were happy with the outcome of the procedure while 20 (39%) were not: four patients were unsure whether a change had occurred. Conclusion Augmentation ileocystoplasty is a valuable alternative for women with intractable urge incontinence. However, these patients and their physicians should be aware of its limitations, specifically the possibility that incontinence may persist and the high probability of the need for self-catheterization, with potential subsequent urinary tract infection. Editorial Comment: After behavioral modification, pharmacological therapy and electrical stimulation, the only alternatives remaining for the treatment of urge incontinence are neuromodulation, augmentation cystoplasty, autoaugmentation, urinary diversion and catheterization. These authors succinctly, but in great detail, report the long-term course of women with idiopathic urge incontinence who have undergone augmentation cystoplasty. Although 53% of patients were “happy,” clearly this procedure is not without problems. Neuromodulation is a possible alternative at this point but long-term data are lacking. Unfortunately, there are few other alternative management Strategies. Alan J. Wein, M.D. Proposed Cutoff Values to Define Bladder Outlet Obstruction in Women
S. CMSAGNE,P. A. B E ~ I E RF., m,C. G. ROEHRBORN, J. S. REISCHAYD P. E. ZIX~IMERN, Department of urology and Academic Computing Services (Biostatistics), University of Texas Southwestern Medical Center, Dallas, Texas, and Urology Departments, H6pital Edouard Herriot, Lyon and Hbpital Tenon, Paris, France Urology, 51: 408-411, 1998 Objectives. There is no accepted urodynamic definition of outlet obstruction in women. Currently, the diagnosis is made on the basis of history and radiographic and endoscopic findings. The goal Of this study is to design a pressure-flow nomogram (PdetQmaxfQmax) and define cut-off values for ~bstruction-
1039
1040
VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY
Methods. Two groups were studied prospectively in an open study: 124 control and 35 clinically obstructed patients. All had a complete history, physical examination, normal neurologic evaluation, cystoscopy, voiding cystography, and urodynamics-with-pressure-flowstudy. Pressure-flow plot and receiver operator characteristic curves (ROCs) were constructed to determine optimal cut-off values to predict obstruction for peak flow rate (Qmax) and detrusor pressure at maximal flow (PdetQmax). Results. The etiology of obstruction was previous anti-incontinence surgery (n = 13), large cystocele (n = l l ) , urethral stricture (n = 61,and other (n = 5). On the basis of ROC curves, using cut-off values of Qmax of 15 mLJs or less and 12 mUs or less, sensitivity was 85.7% and 71.4%, and specificity 78.2% and 90.3%, respectively. Using cut-off values of PdetQmax of more than 25 and more than 30 cm H,O, sensitivity was 74.3% and 71.4%, and specificity 79.8% and 88.7%, respectively. Using a combined cut-off value of Qmax of 15 mUs or less and PdetQmax of more than 20 cm H,O, sensitivity was 74.3% and specificity was 91.1%. Conclusions. Based on this prospective, controlled study, preliminary cut-off values were obtained for refining the definition of outlet obstruction in women.
Editorial Comment: The authors conclude that the best cutoff value f o r u r o d y n a m i c d l y defined obstruction in women is a detrusor pressure at peak flow between 25 and 30 cm. water. When a similar analysis w a s used f o r peak flow, the best cutoff value w a s between 10 and 15 ml. per second. When peak flow and detrusor pressure at peak flow w e r e simultaneously used, the best combination w a s a peak flow of 15 ml. per second or less and a detrusor pressure at peak flow of m o r e than 20 cm. water. According to this last definition, many of m y patients would h a v e obstruction. Detrusor pressure at peak flow f o r the control group in this series w a s 20.1 f 10.2 cm. water. For the 3 groups with clinical obstruction the corresponding pressure w a s 42.3 f 23,42.1 f 17.3 and 52.4 f 31.9. These authors cite others as using parameters of peak flow from 12 to 15 ml. per second and detrusor pressure peak flow of greater than 50 cm. w a t e r as criteria for diagnosing bladder outlet obstruction in the female patient. I agree with the conclusion of Chassagne et a1 that "the lack of long term outcome data f o r the obstructed group is a recognized shortcoming of this s t u d y . . . although a pressure flow nomogram can be constructed to help improve the diagnosis of obstruction, additional outcome data are still required before full validation can be made." Alan J. Wein, M.D. Urethral Obstruction in Women
V. W. N I ~AND I M.FICCAZOCA, Department of Urology, New York University Medical Center, New York, New York Curr. Opin. Urol., 7: 211-214, 1997 Urethral or bladder outlet obstruction is an infrequently diagnosed cause of voiding dysfunction in women. This may reflect a low index of suspicion by clinicians rather than a truly low incidence. Recent work has highlighted the prevalence of bladder outlet obstruction in women and suggests new ways to diagnose its many causes. Editorial Comment: This thoughtful article is about nonneurogenicbladder outlet obstruction in women. The authors review various urodynamic definitions of bladder outlet obstruction in women and conclude that it is difficult to make the diagnosis based on pressure flow parameters alone. They advocate defining bladder outlet obstruction in women as radiographic evidence of obstruction between the bladder neck and distal urethra in the presence of a sustained detrusor contraction without the use of strict pressure flow criteria. Since many women without bladder outlet obstruction void with an extremely low detrusor pressure, bladder outlet obstruction in these women might not increase detrusor pressure much above 20 cm. water. However, other women who have obstruction might have increased detrusor pressure at peak flow to 40 to 50 cm. water or e v e n higher. This type of definition seems more reasonable than relying on pressure flow criteria alone in a female patient. In this series peak flow in the obstructed group (40 patients) was 10.3 2 1.5 ml. per second,while in the unobstructed group it w a s 21.4 0.9 ml. per second. Corresponding detrusor pressures at peak flow were 42.9 f 2.2 cm. and 21.4 f 1.3 cm. water, respectively. Post-void residuals in the 2 groups were 148 f 19 ml. and 34 -C 11 ml., respectively. Alan J. Wein, M.D.
*
Pressure-Flow Studies: An Evaluation of Within-Testing Reproducibility-Validity sured Parameters
F. HANSEN,L. OISEN, A. ATAN,H. JACOBSEN AND J. NORDLING, Department
of the Mea-
of Urology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark Neurourol. Urodynam., 16: 521-532, 1997 The within-examination variation in selected test parameters in repeated pressure-flow studies was determined in a retrospective study of consecutive pressure-flow examinations in 105 patients. It was
Editorial Comment: Okada et a1 discuss the use of propiverine hydrochloride, a synthetic musculotropic antispasmodic agent, and the treatment of urge and stress incontinence. There were minimal side effects and no controls in their study. Although the results are suggestively promising, double-blind control studies are obviously necessary. Vaidyananthan et al describe the significant increase in the quality of life of spinal cord injured patients who are able to manage with intermittent catheterization plus pharmacological therapy to inhibit bladder contractility. Abrams et a1 reveal a promising new advance in pharmacological therapy for patients with overactive bladder. They describe tolterodine as a new antimuscarinic agent with affinity and specificity for muscarinic receptors in the bladder equal to oxybutynin but with 8 times less affinity for muscarinic receptors in the salivary gland. Alan J. Wein, M.D. Long-Tern Results and Complications of Augmentation Ileocystoplasty for Idiopathic Urge Incontinence in Women
S. A. AWAD,H. M. AL-ZAHRANI,J. B. GAJEWSKIAND A. A. BOURQUE-KEHOE, Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada Brit. J. Urol., 81: 569-573, 1998 Objective To assess the long-term (3-9 years) results of augmentation ileocystoplasty for nonneurogenic female urge incontinence in terms of continence, the need for intermittent self-catheterization and the need for additional or auxiliary treatment, to define the long-term complications and to assess the patients’ satisfaction with the outcome. Patients and methods The study comprised 51 women who underwent augmentation ileocystoplasty for non-neurogenic urge incontinence between November 1987 and December 1993; 27 patients had associated interstitial cystitis. All patients had exhausted conservative methods, with a n unsatisfactory outcome. All patients were interviewed about the results of the procedure, and their charts reviewed and updated with relevant information. Results Within a mean (range) follow-up of 75.4 (36-109) months, 27 patients (53%)were completely continent, 13 (25%) had occasional leaks and nine (18%) continued to have disabling urge incontinence frequently requiring pads. Regular self-catheterization was needed by 20 (39%) patients while the rest emptied adequately with no or minimal residual volumes. Additional pharmacotherapy had to be used by 12 (24%) patients. Three patients later developed stress urinary incontinence and were managed with fascia1 sling procedures. The patch was revised in two patients and excised from four others because they had high residual volumes and uncontrollable infections. Two patients had an ileal conduit diversion for persistent incontinence. The most common complication was recurrent urinary tract infections, seen in 22 patients using intermittent self-catheterization. Mucus retention occurred regularly in 10 patients, six had chronic diarrhoea, four had latent bowel obstruction, one developed a bladder stone, one a n incisional hernia and one developed patch necrosis and perforation. Twenty-seven patients (539) were happy with the outcome of the procedure while 20 (39%) were not: four patients were unsure whether a change had occurred. Conclusion Augmentation ileocystoplasty is a valuable alternative for women with intractable urge incontinence. However, these patients and their physicians should be aware of its limitations, specifically the possibility that incontinence may persist and the high probability of the need for self-catheterization, with potential subsequent urinary tract infection. Editorial Comment: After behavioral modification, pharmacological therapy and electrical stimulation, the only alternatives remaining for the treatment of urge incontinence are neuromodulation, augmentation cystoplasty, autoaugmentation, urinary diversion and catheterization. These authors succinctly, but in great detail, report the long-term course of women with idiopathic urge incontinence who have undergone augmentation cystoplasty. Although 53% of patients were “happy,” clearly this procedure is not without problems. Neuromodulation is a possible alternative at this point but long-term data are lacking. Unfortunately, there are few other alternative management Strategies. Alan J. Wein, M.D. Proposed Cutoff Values to Define Bladder Outlet Obstruction in Women
S. CMSAGNE,P. A. B E ~ I E RF., m,C. G. ROEHRBORN, J. S. REISCHAYD P. E. ZIX~IMERN, Department of urology and Academic Computing Services (Biostatistics), University of Texas Southwestern Medical Center, Dallas, Texas, and Urology Departments, H6pital Edouard Herriot, Lyon and Hbpital Tenon, Paris, France Urology, 51: 408-411, 1998 Objectives. There is no accepted urodynamic definition of outlet obstruction in women. Currently, the diagnosis is made on the basis of history and radiographic and endoscopic findings. The goal Of this study is to design a pressure-flow nomogram (PdetQmaxfQmax) and define cut-off values for ~bstruction-
1039
1040
VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY
Methods. Two groups were studied prospectively in an open study: 124 control and 35 clinically obstructed patients. All had a complete history, physical examination, normal neurologic evaluation, cystoscopy, voiding cystography, and urodynamics-with-pressure-flowstudy. Pressure-flow plot and receiver operator characteristic curves (ROCs) were constructed to determine optimal cut-off values to predict obstruction for peak flow rate (Qmax) and detrusor pressure at maximal flow (PdetQmax). Results. The etiology of obstruction was previous anti-incontinence surgery (n = 13), large cystocele (n = l l ) , urethral stricture (n = 61,and other (n = 5). On the basis of ROC curves, using cut-off values of Qmax of 15 mLJs or less and 12 mUs or less, sensitivity was 85.7% and 71.4%, and specificity 78.2% and 90.3%, respectively. Using cut-off values of PdetQmax of more than 25 and more than 30 cm H,O, sensitivity was 74.3% and 71.4%, and specificity 79.8% and 88.7%, respectively. Using a combined cut-off value of Qmax of 15 mUs or less and PdetQmax of more than 20 cm H,O, sensitivity was 74.3% and specificity was 91.1%. Conclusions. Based on this prospective, controlled study, preliminary cut-off values were obtained for refining the definition of outlet obstruction in women.
Editorial Comment: The authors conclude that the best cutoff value f o r u r o d y n a m i c d l y defined obstruction in women is a detrusor pressure at peak flow between 25 and 30 cm. water. When a similar analysis w a s used f o r peak flow, the best cutoff value w a s between 10 and 15 ml. per second. When peak flow and detrusor pressure at peak flow w e r e simultaneously used, the best combination w a s a peak flow of 15 ml. per second or less and a detrusor pressure at peak flow of m o r e than 20 cm. water. According to this last definition, many of m y patients would h a v e obstruction. Detrusor pressure at peak flow f o r the control group in this series w a s 20.1 f 10.2 cm. water. For the 3 groups with clinical obstruction the corresponding pressure w a s 42.3 f 23,42.1 f 17.3 and 52.4 f 31.9. These authors cite others as using parameters of peak flow from 12 to 15 ml. per second and detrusor pressure peak flow of greater than 50 cm. w a t e r as criteria for diagnosing bladder outlet obstruction in the female patient. I agree with the conclusion of Chassagne et a1 that "the lack of long term outcome data f o r the obstructed group is a recognized shortcoming of this s t u d y . . . although a pressure flow nomogram can be constructed to help improve the diagnosis of obstruction, additional outcome data are still required before full validation can be made." Alan J. Wein, M.D. Urethral Obstruction in Women
V. W. N I ~AND I M.FICCAZOCA, Department of Urology, New York University Medical Center, New York, New York Curr. Opin. Urol., 7: 211-214, 1997 Urethral or bladder outlet obstruction is an infrequently diagnosed cause of voiding dysfunction in women. This may reflect a low index of suspicion by clinicians rather than a truly low incidence. Recent work has highlighted the prevalence of bladder outlet obstruction in women and suggests new ways to diagnose its many causes. Editorial Comment: This thoughtful article is about nonneurogenicbladder outlet obstruction in women. The authors review various urodynamic definitions of bladder outlet obstruction in women and conclude that it is difficult to make the diagnosis based on pressure flow parameters alone. They advocate defining bladder outlet obstruction in women as radiographic evidence of obstruction between the bladder neck and distal urethra in the presence of a sustained detrusor contraction without the use of strict pressure flow criteria. Since many women without bladder outlet obstruction void with an extremely low detrusor pressure, bladder outlet obstruction in these women might not increase detrusor pressure much above 20 cm. water. However, other women who have obstruction might have increased detrusor pressure at peak flow to 40 to 50 cm. water or e v e n higher. This type of definition seems more reasonable than relying on pressure flow criteria alone in a female patient. In this series peak flow in the obstructed group (40 patients) was 10.3 2 1.5 ml. per second,while in the unobstructed group it w a s 21.4 0.9 ml. per second. Corresponding detrusor pressures at peak flow were 42.9 f 2.2 cm. and 21.4 f 1.3 cm. water, respectively. Post-void residuals in the 2 groups were 148 f 19 ml. and 34 -C 11 ml., respectively. Alan J. Wein, M.D.
*
Pressure-Flow Studies: An Evaluation of Within-Testing Reproducibility-Validity sured Parameters
F. HANSEN,L. OISEN, A. ATAN,H. JACOBSEN AND J. NORDLING, Department
of the Mea-
of Urology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark Neurourol. Urodynam., 16: 521-532, 1997 The within-examination variation in selected test parameters in repeated pressure-flow studies was determined in a retrospective study of consecutive pressure-flow examinations in 105 patients. It was