Urodynamic studies in the evaluation of the older ... - SAGE Journals

Therapeutic Advances in Urology

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Urodynamic studies in the evaluation of the older man with lower urinary tract symptoms: when, which ones, and what to do with the results

Ther Adv Urol (2010) 2(5-6) 187194 DOI: 10.1177/ 1756287210385924 ! The Author(s), 2010. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav

Ahmad Abdul-Rahman, Samih Al-Hayek and Mohammed Belal

Abstract: Lower urinary tract dysfunction is a major cause of morbidity and decreased quality of life in older men. Most urinary dysfunctions in the elderly are multifactorial in origin and associated with a broad spectrum of mental and physical conditions. In this population, it is essential to have a comprehensive assessment of the lower urinary tract, functional impairments and concurrent medical diseases. A holistic and individualized approach to management is important. Urodynamic studies (UDS) are objective tests which provide a major contribution to our understanding of the pathophysiology of lower urinary tract symptoms (LUTS). Urodynamic findings in older men may include common diagnoses such as bladder outlet obstruction and urinary incontinence. However, coexisting conditions such as detrusor overactivity and impaired detrusor contractility are common in older men. The identification of these conditions is necessary to appropriately counsel patients regarding treatment options. Simple urodynamic tests should be used whenever possible such as uroflowmetry and residual volume estimation. However, in complicated cases more invasive tests such as pressure flow studies are important to help choose the best treatment. Keywords: urodynamic studies, older men, lower urinary tract symptoms

Introduction Lower urinary tract symptoms (LUTS) increase with age. They have significant effects on quality of life in older men [Parsons et al. 2008]. In addition they have been associated with an increased risk of falls [Parsons et al. 2009]. Urinary incontinence (UI) is the most common problem and is reported to affect 2290% of those in nursing homes [Anger et al. 2006]. Benign prostatic enlargement (BPE) may cause infravesical obstruction in nearly 50% of men over 60 [Gomes et al. 2001]. Other important changes observed with age include an increased prevalence of involuntary detrusor contractions and increased postvoid residual (PVR) volume [Homma et al. 1994]. The evaluation of older men with LUTS requires an understanding of the physiology of storing and voiding urine as well as the changes associated with aging. Most urinary problems in older men are multifactorial in origin, demanding a

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comprehensive assessment of the lower urinary tract, functional impairments, and concurrent medical diseases. Increasing urine output during the nighttime, even in the absence of congestive heart failure, BPE or other medical conditions, is associated with nocturia in the majority of healthy individuals in this age group.

Correspondence to: Ahmad Abdul-Rahman, MD, MSc (Urol), MRCS Clinical Research Fellow, Registrar in NeuroUrology, Spinal Injuries Centre, Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, UK [email protected]

Clinical evaluation is an important aspect in the assessment of older patients with LUTS. The evaluation has to characterize the urinary symptoms as well as the patient’s general medical condition and mental status. This will enable the clinician to make a working diagnosis and identify potentially reversible pathologic conditions. It is important to recognize previous urological surgeries, history of stroke, dementia, Parkinson’s disease and current medications. Physical examination can help identify the causes of urinary dysfunction and evaluate associated comorbidities and the functional status of the patient.

Samih Al-Hayek, LRCP (Lond), LRCS (Eng), MRCS, MD (Lond) Specialist Registrar in Urology, Gloucestershire Royal Hospital, Gloucester, UK Mohammed Belal, MA BChir, FRCS (Urol) Urology Fellow, Alfred Hospital, Melbourne, Australia

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Therapeutic Advances in Urology 2 (5-6) Urodynamics (UDS) are the gold standard objective investigation in evaluating LUTS in general. However, due the nature of LUTS in older men and the difficulty in establishing the underlying diagnosis, UDS may play an important role in managing these patients. There is a perception that UDS is invasive and associated with significant morbidity. In keeping with this most international guidelines suggest that invasive UDS should not be performed in the routine investigation of these patients [American Urological Society, 2003]. In this article we outline the types of UDS, when they could be used and how to interpret their results in helping the management of LUTS in older men.

Urodynamics UDS studies involve the assessment of the function and dysfunction of the urinary tract by appropriate methods as defined by the International Continence Society (ICS) [Abrams et al. 2002]. They encompass a variety of diagnostic tests, including uroflowmetry, cystometry, urethral pressure profile, pressureflow studies (PFSs), electromyography of the pelvic floor, and simultaneous radiographic visualization of the lower urinary tract (videocystometrogram). These tests can be used alone or in combination to evaluate lower urinary tract function.

Uroflowmetry Uroflowmetry is the measurement of urine flow over time. It is an objective and noninvasive urodynamic study that may reveal an abnormal voiding phase of the micturition cycle. The single most important parameter of the uroflowmetry is the maximum urinary flow (Qmax), which is volume dependent [Drach et al. 1979]. In general, a Qmax 100 ml, with the absence of severe BOO, suggests a reduction in detrusor contractility. In general there may be an agedependent decrease in contractility [Bonde et al. 1996; Griffiths et al. 1996]. Filling cystometry Cystometry is an invasive test for the measurement of the bladder’s pressures during the filling (storage) phase of the micturition cycle. Several parameters are studied during cystometry, including bladder capacity, sensation, compliance, presence of involuntary detrusor contractions and abdominal leak point pressure.

Table 1. Normal values for uroflowmetry [Abrams and Torrens, 1979]. Gender

Age (years)

Flow rate (ml s1)

Male

60 50

>22 >18 >13 >25 >18

Female


As noted before, many aspects of the physiology of micturition may change as a part of normal aging and may or may not play a role in voiding dysfunction. Detrusor overactivity (DO) is a very common urodynamic finding in the elderly, contributing to most cases of their urinary incontinence [Payne, 1998]. DO can also be observed in asymptomatic older patients, occurring in up to 50% [Andersen et al. 1978]. This fact shows the importance of reproducing the patient’s symptoms during the urodynamic test and analysing its results in conjunction with all other information obtained from history and clinical examination. DO and loss of the bladder compliance are cystometric abnormalities that may be present in a significant number of patients with BOO [Abrams et al. 1979]. They may improve in many patients after the relief of obstruction, but in the older population, DO and urgency incontinence may be the result of age-associated changes and not secondary to obstruction [Madersbacher et al. 1999]. Resnick and Yalla described detrusor hyperactivity with impaired contractile function (DHIC) in the older population [Resnick and Yalla, 1987]. In this condition DO may be associated with impaired detrusor contractility, even in the absence of BOO. Clinically, patients with DHIC may be no different from patients with DO with normal contractility. UDS of patients with DHIC have higher PVR urine and are not capable of generating effective detrusor contractions in the voiding phase of the study. No signs of BOO or sphincter abnormalities were found in their urodynamic tests. However, the pathogenic process that leads to DHIC is still unknown [Griffiths et al. 2002]. DHIC must be distinguished from BOO, which can also lead to high PVR and may be accompanied by DO in up to 50% of patients [Gomes et al. 2001]. The treatment for BOO can involve alpha-blocking agents or surgical correction of the obstruction, while patients with DHIC have a limited range of therapeutic options. Furthermore, patients with urge incontinence and normal detrusor contractility can be safely treated with bladder training and anticholinergics, while patients with DHIC are at high risk of developing urinary retention when they take anticholinergics. The clinical implications associated with the diagnosis of DHIC are very

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Therapeutic Advances in Urology 2 (5-6) important and stress the need for UDS in older patients with voiding dysfunction.

with no obstruction if BOOI 40.

However, UDS facilities are not available in all hospitals. Eyeball UDS may provide useful information on the bladder behaviour during filling. This is a simple bedside evaluation using a urethral catheter connected to a 50 ml syringe that is used to fill the bladder under gravity.

Detrusor function during voiding is classified by the ICS into three categories [Abrams et al. 2002]: normal, underactive and acontractile. Normal detrusor contractility is defined as a voluntarily initiated continuous detrusor contraction that leads to complete bladder emptying within a normal time span, in the absence of obstruction. However, DUA is defined as a detrusor contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span. To distinguish those with DUA, another index was used; the bladder contractility index (BCI).

Pressure-flow studies This test assesses the voiding phase of the micturition cycle. It measures the flow rate whilst intravesical, abdominal pressures are being monitored and detrusor pressure calculated. Disorders of the voiding phase of the micturition cycle are very common in older patients. The exact cause of voiding dysfunction can only be determined with PFSs as they can differentiate between BOO and DUA. Diokno and colleagues found 47% of 19 men older than 60 years of age to be obstructed, but the criteria for diagnosing obstruction were not well described [Diokno et al. 1994]. The test could be performed in most patients undergoing filling cystometry, unless the patient has a significant functional disability or cognitive impairment. The patient is instructed to void when he reports that his bladder is full.

BCI ¼ p det Qmax þ 5 Qmax : A BCI below 100 is indicative of DUA. When performing the PFS, the BOOI and BCI could be calculated and will identify those with BOO and DUA. Men can be divided into obstructed, equivocal and unobstructed according to their BOOI: BOOI >40 are obstructed; BOOI 2040 are equivocal; and BOOI 15/s) and a very high detrusor pressure, but this condition is not very common, and the patients are usually managed in the same fashion as those with a low flow and high detrusor pressure. The ICS nomogram and the corresponding equation of bladder outlet obstruction index (BOOI) have been used widely to define men with BOO. They were divided into three categories based on their BOOI as indicated by ICS nomogram (BOOI ¼ p det Qmax 2 Qmax) [ Lim and Abrams 1995]. They were defined as

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Videocystometrogram Videocystometrogram (VCMG) studies involve filing the bladder with a radiopaque contrast medium during the filling cystometry to allow simultaneous fluoroscopic visualization of the bladder and urethra during the filling and voiding phases. This technique allows simultaneous pressure measurements to be obtained along with structural information (Figure 2). VCMG studies require more expensive and complex equipment. Most information needed in clinical practice could be obtained from standard UDS. For these reasons, most units perform VCMG in specific cases only. This includes complex cases involving suspected anatomic abnormalities, failure of previous surgical procedures or associated neurological disorders. Despite the advantages of having anatomical information associated with the functional data, the indications for VCMG are limited in older patients.


A Abdul-Rahman, S Al-Hayek et al.

Figure 2. Videocystometrography.

The urethral pressure profile is a graph indicating the intraluminal pressure along the length of the urethra. The urethral pressure profile is a specific study, in which a special design catheter is pulled through the urethra at a slow, continuous rate. The resulting ‘bell shaped’ curve illustrates the function of the urethra from the beginning of the bladder neck out through the meatus [Jorgensen and Jensen, 1996]. The passive urethral resistance relation (PURR) developed by Schafer in 1983 constitutes a simplified model of Griffiths’ urethral resistance relation [Schafer, 1983]. The PURR curve describes the relationship between pressure and flow during the period of lowest urethral resistance, and therefore defines the lowest urethral resistance during a single voiding event. The PURR was the first attempt to quantify relevant features of the voiding cycle describing the interplay of detrusor capability and bladder outlet resistance. Schafer subsequently modified the PURR by using a straight line instead of a parabolic curve [Schafer, 1990]. Schafer divided this linear PURR (Lin PURR) curve into seven zones labelled 0 to VI corresponding to increasing grades of obstruction: grades 0 and 1, no obstruction; grade 2, equivocal or mild obstruction; grades 36, increasing severity of obstruction. The boundary between grades 2 and 3 corresponds to the boundary between equivocal and obstructed in the AbramsGriffiths nomogram. Discussion LUTS in older men are complex and multifactorial. Many patients complain of poor flow.


The basic evaluation of LUTS in old men should be done in the clinic prior to providing UDS, including relevant medical history, assessment of symptoms and bother, physical examination, urine analysis and a prostate-specific antigen (PSA) test. The main usage of UDS is in the evaluation of men with LUTS suggestive of BOO. The diagnosis of BOO cannot be made from LUTS alone. Urinary flow rate measurement is very useful in the initial assessment and also during or after treatment to determine response. It is recommended as part of the specialized evaluation to be performed before embarking on any active therapy as it is a noninvasive test and has clinical value. Approximately one third of older men with LUTS do not have urodynamic evidence of obstruction. Similarly, a low flow rate is not diagnostic of BOO because 2530% of patients with low flow rate have detrusor hypocontractility as their main problem, whereas a normal or high flow rate does not rule out obstruction as 7% of symptomatic men with a Qmax greater than 15 ml/s are obstructed. Ideally two flow rates should be obtained, both with a volume greater than 150 ml voided urine. If such voided volume cannot be obtained by the patient despite repeated recordings, the Qmax results at the available voided volumes should be considered. UDS studies are recommended before invasive therapy in men with a Qmax greater than 10 ml/s. When Qmax is less than 10 ml/s then obstruction is most likely and PFSs are not necessarily needed. UDS are of proven value in the evaluation of patients before invasive therapies, or when a precise diagnosis of BOO is important.

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Therapeutic Advances in Urology 2 (5-6) LUTS in elderly OAB-BOO

Initial tests • Urinalysis • Validated Questionnaire • FVC • Flow rate • Post voiding residual

OAB No evidence of BOO

Medical Management

BOO

BOO + OAB

Medical therapy

Flow Rate < 10ml/s

Yes

No

Botox Neuromodulation

Pressure-Flow Studies No

Obstruction

Treat appropriately

Yes

Surgery

Figure 3. Management of LUTS in elderly men. LUTS, lower urinary tract symptoms; FVC, frequency volume chart; BOO, bladder outlet obstruction; OAB, overactive bladder.

Invasive UDS in the form of PFSs should be performed only if the information obtained will affect the treatment decision, in particular, if surgery is being contemplated. There is evidence that the outcome of outlet obstruction surgery is significantly better in those patients with urodynamically proven BOO. The role of PFS is more evident in older men with LUTS suggest BOO and a history of neurologic disease such as cerebrovascular accident (CVA), multiple sclerosis (MS) or Parkinson’s disease which affect the detrusor and external sphincter function. When patients do not to have BOO and still have LUTS, they are less likely to benefit from invasive treatments such as surgery designed to relieve outlet obstruction. Hence, it is recommended that these patients’ symptoms should be treated in an appropriate fashion, aimed at other underlying disease processes including anticholinergics, bladder behavioural training. It is recommended to have PFS in men over the age of 80 years prior to trans-resection of the prostate (TURP) [Oelke et al. 2009]. This is

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because the morbidity of TURP in this age group of patients is higher, and their symptoms could be due to conditions other than BOO, such as changes related to ageing [Madersbacher et al. 1999]. Some of the changes noted with ageing include decrease of Qmax, an increase of PVR volume, a decline in bladder capacity and of bladder compliance [Madersbacher et al. 1996]. The most important parameter of the PFS is detrusor pressure at maximum urinary flow rate. With these changes, there is a high percentage of men over the age of 80 who have a reduced Qmax of 1015 ml/s and an International Prostate Symptom Score (IPSS) exceeding 7 without BOO [Madersbacher et al. 1999, 1998, 1996]. An operation in the form of TURP would not be helpful in these cases. The management of LUTS in elderly men is summarized in Figure 3. Abnormal voiding affects the bladder’s ability to store urine and results in abnormal cystometrogram and commonly causes DO. As a result, older patients have a worse outcome, and DO is


A Abdul-Rahman, S Al-Hayek et al. likely to persist following surgery to relieve BOO [Gormley et al. 1993]. Similarly, older patients with neurological diseases, such as Parkinson’s disease, CVA, and MS are at a high-risk of having a poor outcome after prostate surgery and should be investigated with complete UDS before a decision is made to operate [Madersbacher et al. 1996]. Establishing the cause of voiding dysfunction in older men poses a real challenge. It could be due to BOO or DUA. The only way to distinguish between these two is to perform PFSs. This becomes more important when surgery is being considered, since improved outcome is obtained in those with documented BOO [Drach et al. 1979]. Older patients might have asymptomatic bladder dysfunction such as DO and a reduction in the bladder capacity. All of these conditions could be demonstrated using UDS [Homma et al. 1994]. In some cases, these findings could present with symptoms that mimic common urological problems such as stress incontinence or BOO. For these reasons, some authors [Abrams et al. 2002] believe UDS should be used liberally in the elderly. However, some UDS are invasive and are associated with complications and side effects. Drach and colleagues showed a significant association between age and the presence of asymptomatic bacteriuria before cystometry and between this bacteriuria and urgency without DO on cystometry [Drach et al. 1979]. Therefore, the type of test and when to perform it depends on the clinical evaluation and the potential treatment plan. In general, invasive UDS evaluations are only indicated in specific cases and only after ruling out reversible causes of voiding dysfunction. In older patients UDS are indicated in those with significant LUTS and coexisting neurologic disease, previous surgery on the lower urinary tract, high PVR volumes, and whenever a surgical procedure is being considered. Comprehensive UDS is recommended in difficult and intractable cases that have not responded to behavioural or medical therapy, and in whom further therapy is desired. Complicated cases in patients with high comorbidities require detailed assessment. Conclusion LUTS are common, complex and multifactorial in older men. They are usually associated with significant comorbidities and often cognitive impairment. The assessment should always


include a detailed medical history, physical examination and simple tests in the form of urinalysis and frequency volume diaries. Simple UDS tests such as uroflowmetry and PVR are very helpful and are incorporated in most international guidelines on LUTS. However, more invasive detailed UDS such as filling cystometry and PFSs are indicated in specific cases, especially before surgery. The benefits and risks from the tests should always be discussed with the patients before undertaking UDS. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflict of interest statement None declared.

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