Is bladder voiding efﬁciency useful to

(1)

Disponibleenlignesur

ScienceDirect

www.sciencedirect.com

ORIGINAL ARTICLE

Is bladder voiding efﬁciency useful to

evaluate voiding function in women older than 65 years?

L’efﬁcacité mictionnelle de la vessie est-elle utile pour évaluer la fonction vesicale chez les femmes de plus de 65 ans?

F.A. Valentini

^a^,∗

, B.G. Marti

^a

, G. Robain

^a

, P.E. Zimern

^b

, P.P. Nelson

^a

aSorbonneuniversitéandhôpitalRothschild,75012Paris,France

bUTSouthwesternMedicalCenterinDallas,7539TX,UnitedStates

Received3July2019;accepted12August2019 Availableonline28August2019

KEYWORDS Bladdervoiding efﬁciency;

Ageing;

Woman;

Urodynamics

Summary

Aims.—The aimsofthestudy were toevaluate thereproducibilityofbladdervoidingeffi- ciency(BVE)betweenfreeflow(FF)andintubatedflow(IF)inoldwomen,andtosearchfora relationshipofthisindexwithcomplaintandurodynamicdiagnosis.

Methods.—Urodynamictracingsofnon-neurologicwomenreferredforinvestigationofvarious lowerurinarytractsymptoms(LUTS)wereanalyzed.UrodynamicstudyincludedoneFFfollowed byonecystometryandIF.Postvoidresidualvolume(PVR)wasmeasuredusingaBladder-scan.

Exclusioncriteriawerevoidedvolume<100mlandprolapseofgrade>2.

Results.—Onehundredandninetywomenmetthestudycriteria.Themeanagewas74±6 years[65—96years].Themaincomplaintwasurinaryincontinence:stress(26),urge(53)and mixed(56). Forty-fourwomenhad variouscomplaints withoutincontinence. OverallBVE IF (77.6±25.8) was significantly lower than BVE FF (90.4±15.3) (P<.0001). Age sub-groups stratification ledsimilar results.BVE IFwas significantly lowerthanBVE FF inwomenwith incontinencewhateverthecause.UrodynamicdiagnosiswasposedaccordingtotheICS/IUGA recommendationsand2sub-groupsdefinedaccordingwithinvolvementofdetrusor.BVEIFwas significantlylowerthanBVEFFfordetrusordysfunction,exceptfordetrusoroveractivity.

∗Correspondingauthorat:Servicedemédecinephysiqueetderéadaptation,hôpitalRothschild,5,rueSanterre,75012Paris,France.

E-mailaddress:favalentini@gmail.com(F.A.Valentini).

https://doi.org/10.1016/j.purol.2019.08.270

(2)

Conclusion.—In thislargecohortofoldnon-neurologicwomenstudiedurodynamicallyfora varietyofLUTS,BVEishigherwhenevaluatedfromaFFwhateverageandfor complaintof urinaryincontinence.Inaddition,alowBVEvaluefromanIFmaysuggestadetrusordysfunction.

Levelofevidence.—4.

MOTSCLÉS Éfﬁcacité

mictionnelledela vessie;

Vieillissement; Femme; Urodynamique

Résumé

Objectifs.—Lesobjectifsdel’étudeétaientd’évaluerlareproductibilitédel’efﬁcacitémic- tionnelledelavessie (EMV)entredébitmétrielibre (DL)etinstantanémictionnel(IM) chez lesfemmesâgées,etderechercherunerelationentrecetindex,laplainteetlediagnostic urodynamique.

Méthodes.—Lestracésurodynamiquesdepatientesnonneurologiquesprésentantdiverstrou- blesdubas appareilurinaireontétéanalysés. Chaquebilan urodynamiquecomprenaitune débitmétrielibre suivieparune cystomanométrie avecIM. Lerésidu postmictionnel (RPM) était mesuré par échographie (Bladder-scan). Les critères d’exclusion étaient un volume uriné<100ml,uneexpulsionducathéterpendantl’IMetunprolapsusdegrade≥2.

Résultats.—Centquatrevingtdixpatientsremplissaientlescritèresd’inclusion.L’âgemoyen était74±6ans[65—96ans].Pour146patienteslaplainteprincipaleétaituneincontinence:

pour26uneincontinenceurinaired’effort,pour53uneurgenturie,63uneincontinencemixte.

Les autres plaintes étaient pour 22 une pollakiurie, pour 9 une dysurie et pour 18 divers TUBA (infectionsurinaires récidivantes, cystite interstitielle, douleurs).Globalement l’EMV IM(77,6±25,8)étaitsignificativementinférieuràl’EMVDL(90,4±15,3)(p<0,0001).Lastrat- ificationen sous-groupesd’âgecroissantconduisait àdesrésultatssimilaires.Le diagnostic urodynamique(DU)étaitposeselonlesrecommendationsdel’ICS/IUGAet2sous-groupesdéfi- nisenfonctiondel’implicationdudetrusor.l’EMVIMétaitsignificativementinférieureàl’EMV DLlorsqu’ilexistaitunedysfonctiondudetrusorsauflorsquecelle-ciétaitunehyperactivité.

Conclusion.—Danscetteimportantecohortedepatientesnonneurologiquesprésentantdivers TUBAévaluésenurodynamique,l’EMVestplusélevéeàpartird’uneDLquelquesoitl’âgeet lorsquelaplainteestuneincontinenceurinaire.Parailleurs,unediminutiondel’EMVlorsde l’IMpourraitêtreletémoind’unedysfonctiondudetrusor.

Niveaudepreuve.— 4.

Introduction

Bladder voiding efﬁciency (BVE) is deﬁned as the ratio between voided volume and total bladder capacity [1].

Although easy to calculate, this index is not widely used. Cholhanet al. [2] have evaluated bladder voiding efficiency from 2 successive free uroflowmetries (FF) in pre-menopausal women during proliferative and secre- tory phases of the menstrual cycle. In their study on Trans-Obturator Tape (TOT), Park et al. [3] showed a decreaseofemptyingefficiencyintheearlypost-operative period.

Amongthesefewpublishedstudiestheincidenceofaging wasonly mentioned in the study of Seong et al. [4] who underlinedinwomenasigniﬁcantincreaseoftheprevalence ofdetrusorunder-activitywithpatientagewithBVE%<90 andabsenceofclinicalobstruction.

Recently,thereliabilityofBVEmeasurementfromafree ﬂow(FF)hasbeendemonstratedinthegeneralpopulation [5].

Forthefirsttime,measurementofBVEcouldbetested inalargecohortofnon-neurologicalwomenolderthan65 years.Aimsofourstudywerefirsttosearchforthecondi- tionwhichhadthepredominantinfluenceonevaluationof BVE(FForintubatedflowIF)andsecondthepossiblerela- tionshipswithageing,complaintandurodynamicdiagnosis.

Materials and methods

Urodynamic tracings of non-neurologic women aged≥65 yearswhowerereferredforinvestigationofvariouslower urinary tract symptoms (LUTS) were retrospectively ana- lyzed. Each urodynamic session was performed using a urodynamicunitfromLaborie(MississaugaCanada).Urody- namictestswerecarriedoutaccordingtotheInternational ContinenceSocietyGoodUrodynamicPractices[6].Urody- namic study included one FF in private condition (sitting position)followedbyonecystometry(triplelumenurethral catheter 7F allowing for urethral pressure recording) and

(3)

intubatedflow (IF).Cystometry andIFwere performedin sittingposition,IFwithmaximumrespectfortheprivacyof thepatient(caregivers movingawayfromthe urodynamic unit).Bladderwasfilledwithsalineatroom-temperatureat amedium fillingrate of50ml/min. Postvoidresidualvol- umes(PVR)weremeasuredusingaBladder-scan.Exclusion criteriaweretobeunabletovoidand/orexpelledcatheter duringIF, voided volumeeither fromFFor IF<100ml and prolapseofgrade≥2.

Toevaluatetheroleofageing,thepopulationwasstrat- iﬁedin4agegroups(65—70,71—75,76—80and>80years).

This retrospective study was conducted in accordance withthedeclarationof Helsinki.The localpracticeof our Ethics Committee does not require a formal institutional reviewboardapprovalforretrospectivestudies.

Statistical analysis

Dataarepresentedasmean±SDandrange.Thepairedt- testwasusedforcomparisonofrelatedsamples,analysisof variance(Anova)tocompareunrelatedsamples.Statistical analysis was performed using SAS, version 5.0 (SAS Insti- tute,Inc.,Cary,NC).Allstatisticalresultswereconsidered signiﬁcantatP<0.05.

Results

Onehundred andninety women metstudy criteria. Mean age was 74±6 years [65—96years]. Overall, the volume voidedduringFF(241±138ml)wassigniﬁcantly(P<0.0001) lower thanvoided volume IF(317±140ml). PVR afterFF (30±59ml) was signiﬁcantly lower (P<0.0001) than PVR afterIF(90±113ml).

Overall,BVEIF(77.6±25.8)wassigniﬁcantlylowerthan BVEFF(90.4±15.3)(P<0.0001).

A decrease between BVE FF and BVE IF wasobserved whateveragesub-groups(Table1);eachdecreasewassig- niﬁcant.Withageing,therewasnodecreaseinBVEFFand decreaseofBVEIFwasnotsigniﬁcant.

Maincomplaintwasurinaryincontinence(146 women):

stress(30SUI),urge(53UUI)andmixed(63MUI).Forty-four womenhadvariouscomplaintswithoutincontinence(among which22 hadfrequency(FR)or dysuria(DYS); other com- plaints were recurrent urinarytract infection, interstitial cystitis,pain.

Looking at the main complaint a signiﬁcant decrease in BVE IF when compared to BVE FF was observed in women with urinary incontinence whatever the sub-type (Table2)andinthesub-groupfrequency-dysuriabutifsub- populationswithoutincontinencewereputtogether,there wasnosigniﬁcantdifferencebetweenBVEFF(86.1±22.2) andBVEIF(80.1±23.6)(P=.2347).

Urodynamic diagnosis (UD) wasposed accordingto the ICS/IUGA recommendations. From UD, 2 sub-groups were deﬁned according with involvement of detrusor. The ﬁrst (116 women) had UD related to detrusor dysfunction (21 bladder outletobstructionBOO, 12detrusorhyperactivity withimpaired contractility DHIC, 31 detrusoroveractivity DO (17 phasic and 14 terminal), 52 detrusor underactivity DU).The second sub-group (74 women) hadUD found

‘‘normal’’(24N),relatedtourethraldysfunction(38intrin- sic sphincter deﬁciency ISD and 12 voiding triggered by urethralrelaxationURA).BVEIFwassigniﬁcantlylowerthan BVEFFexceptforDO,ISD,N,andURAurodynamicdiagnosis (Table3).

Lookingattheinﬂuence ofdetrusordysfunctionBVEIF wassigniﬁcantlylowerinthesub-groupwithdetrusordys- function (73.9±26.0 vs. 86.1±20.6 p=.0008) while it is notthe case for BVE FF (88.6±19.4 vs. 89.9±17.7 n.s.) (Table4).

Discussion

Bladdervoidingefficiency(BVE)quantifiesthepercentage of bladder emptied during voiding. If the real definition:

ratio between voided volume and total bladder capac- ityis well respected when this index is evaluatedduring an intubated ﬂow after a cystometry, but during a free uroﬂow as voiding is then initiated at normal desire, beforemaximum bladdercapacityandusuallylong before astrongdesire.Thatconditioncan explainthe difference betweeninitialbladdervolumes(voidedvolumeplusPVR).

Itdoesn’texplainthehigherPVRafterIF.Ithasbeendemon- stratedthata7Furethralcatheterproducesnosigniﬁcant geometrical obstruction [7] but, on the other hand can induce a urethral reﬂexleading to an increased PVR [8].

BVE provides information on the bladder emptying qual- ity while PIP [9] (BCI [1]) is used to evaluate detrusor isovolumetricpressureandIFtoguideurodynamicdiagno- sis.

Themainresultistheabsenceofreproducibilitybetween BVEmeasurement from a FF andfrom an IF in this post- menopausepopulation,asobservedinpre-menopauseand peri-menopause populations [5]. That absence of repro- ducibilityissimilarinagesub-groupsstratiﬁcation.Asmall decreaseofBVEIFwithageingisobservedbutisnotsignif- icant.ThelowervaluesofBVEIFclearlyshowaninability ofoldwomentovoidwithaurethralcatheterinplace.So, BVEFF seemsa more reliableindex of bladder efﬁciency thanBVEIF.

Complaintofincontinenceresultsofsigniﬁcantdecrease inBVEIFwhichcouldbeusefulinformationformanagement.

Looking at the urodynamic diagnosis, an unexpected result is observed: for patients with UD diagnosis of detrusor overactivity, BVE IF is not different from BVE FF. Two hypotheses could be proposed to explain that behavior: first a significant percentage of terminal DO would lead tocomplete bladder emptying and decreased PVR, second increased detrusor contractility induced by DO. The first hypothesis is not verified (14 terminal DO vs. 17 phasic DO) while the second is verified as it has been shown in a previous study that DO pro- duce higher detrusor contractility [10]. In this study the VBN contractility parameter k is 0.57±.06 for the DO sub-groupvs. 0.19±0.29 for the rest ofthe studied pop- ulation.

ThemainlimitationofBVEistheabsenceofcutoffvalue tomakeadiagnosiswithareliableconclusionwhenevalu- atedfromaFForIF.Otherlimitationisthattoourknowledge thereisnouseasanevaluationinbladderfunction.Cholhan andal.proposedBVE>90%fornormaldetrusorfromFFin

(4)

Table1 Bladdervoidingefﬁciency(BVE)fromIFvs.FFinagesub-groups.

Age(y) n BVEIF BVEFF P

65—70 68 81.6±22.5 88.8±17.6 .0136

71—75 54 78.3±28.1 88.4±18.9 .0445

76—80 33 78.2±22.4 92.0±19.8 .0028

>80 35 73.2±25.7 87.7±20.5 .0105

P n.s. n.s.

AllvalueofP<.05issignificant.IF:intubatedflow;FF:freeuroflow:n.s.;nonsignificant.

Table2 Bladdervoidingefﬁciency(BVE)fromIFvs.FFformaincomplaint.

Complaint n BVEIF BVEFF P

SUI 30 75.7±27.1 93.8±10.8 .0021

MUI 63 81.3±23.5 92.4±13.9 .0004

UUI 53 75.8±26.0 85.1±22.8 .0359

FR-DYS 22 74.5±24.8 91.0±14.6 .0149

Other 22 83.1±22.4 83.1±21.9 n.s.

IF:intubatedﬂow;FF:freeuroﬂow;SUI:stressurinaryincontinence;MUI:mixedurinaryincontinence;UUI:urgeurinaryincontinence;

FR-DYS:frequency-dysuria;n.s.:nonsigniﬁcant.

Table3 Bladdervoidingefﬁciency(BVE)fromIFvs.FFforurodynamicdiagnosis.

UD n BVEIF BVEFF P

BOO 21 59.5±25.3 87.6±23.6 .0019

DHIC 12 67.4±32.5 94.8±7.2 .0153

DU 52 76.4±25.3 91.0±16.1 .0001

DO 31 82.5±21.5 84.0±22.9 n.s.

ISD 38 87.4±20.9 92.0±11.5 n.s.

N 24 83.4±21.0 85.6±25.0 n.s.

URA 12 85.5±20.7 88.9±20.0 n.s.

IF:intubatedflow;FF:freeuroflow;UD: urodynamicdiagnosis;BOO:bladderoutletobstruction; DHIC:detrusorhyperactivitywith impaired contractility:DU; detrusor underactivity; DO: detrusor overactivity; ISD:intrinsic sphincterdeficiency; N: normal; URA:

urethralrelaxation;n.s.;nonsigniﬁcant.

Table4 Inﬂuenceofdetrusordysfunctiononbladdervoidingefﬁciency(BVE)fromIF.

n BVEIF BVEFF P

Detrusordysfunction 117 73.9±26.0 88.6±19.4 <.0001

Nodetrusordysfunction 73 86.1±20.6 89.9±17.7 n.s.

P .0008 n.s.

AllvalueofP<.05issignificant.IF:intubatedflow;FF:freeuroflow;n.s.:nonsignificant.

womenyoungerthan45years[2].Somestudieshaveused BVE(BVE>75%)topredictingsurgical successin menwith benignprostaticenlargement [11]orpost-treatmentlarge PVR after intravesical injection of by onabotulinum toxin typeA(BVE<89%)inpatientswithoveractivebladder[12].

Some authors have searched for a BVE criterion to diagnose detrusor underactivity in women; they proposed

association of 3 parameters: P^det.Qmax<20cmH2O, Qmax<15mls⁻¹ and BVE<90% [13] but without obvious superiority [4] over the association of 2 parameters pdet.Qmax<30cmH2O,Qmax<10mls⁻¹[14].

So,despitetheselimitationsanditsretrospectivedesign, our study introduces some characteristics of BVE in older femalepopulation.

(5)

Conclusion

BVEisaneasilymeasuredindex.Inthislargecohortofold non-neurologicwomenstudiedurodynamicallyforavariety ofLUTS,BVEishigherwhenevaluatedfromaFFwhatever ageandforcomplaintofurinaryincontinence.Inaddition, alowBVEvaluefromanIFcouldbetheconsequence ofa detrusordysfunction.

Disclosure of interest

Theauthorsdeclarethattheyhavenocompetinginterest.

References

[1]AbramsP.Bladderoutletobstructionindex,bladdercontractil- ityindexandbladdervoidingefﬁciency:threesimpleindices to deﬁne bladder voiding function. BJU Int 1999;84:14—5, http://dx.doi.org/10.1046/j.1464-410x.1999.00121.x.

[2]CholhanH,JuliaJ,HutchingsT,KocurB.Voidingefﬁciency:a newmethodofassessingbladderemptyingfunctioninwomen.

NAU2010;29:863—4.

[3]ParkSH,ChangYK.Evaluationofpostoperativevoidingefﬁ- ciency after a transobturator tape (TOT) procedure and identiﬁcation of the factors predictive of post TOT voiding dysfunction.JMinimInvasiveGynecol2010;17:S47—68.

[4]Seong JJ, Jung KL, Kwang MK, Harim K, Sung YC, Seung-June O. How do we diagnose detrusor underactivity? Comparison of diagnostic criteria based on an urodynamic measure. Investig Clin Urol 2017;58:247—54, http://dx.doi.org/10.4111/icu.2017.58.4.247.

[5]Valentini FA, Marti BG, Zimmern PE, Robain G, Nelson PP.

Comparisonofbladdervoidingefficiencyinwomenwhencal- culatedfrom a free flow versus anintubated flow. Bladder 2018;5(4):e36,http://dx.doi.org/10.14440/bladder.2018.790.

[6]RosierPFWM,SchaeferW,LoseG,GoldmanHB,GuralnickM, Eustice S, et al. InternationalContinence Society Good

Urodynamic Practices and Terms2016: Urodynamics, uroﬂowmetry, cystometry, and pressure-ﬂow study.

Neurourol Urodyn 2017;36(5):1243—60, http://dx.doi.

org/10.1002/nau.23124[Epub2016Dec5].

[7]Valentini FA, Nelson P, Zimmern PE. Obstructive effect of the urethral catheter during voiding: myth or realty? UrotodayInt J 2013;6(5), http://dx.doi.org/

10.3834/uij.1944-5784.2013.10.08.

[8]ValentiniFA,RobainG,HennebelleDS,NelsonPP.Decreased maximumﬂowrateduringintubatedﬂowis notonlydueto theurethralcatheterinsitu.IntUrogynecolJ2013;24:461—7, http://dx.doi.org/10.1007/s00192-012-1856-2.

[9]Schäfer W. Analysisof bladderoutlet function withthelin- earizedpassive urethral resistance relation, linPURR, and a disease-speciﬁcapproachforgradingobstruction:Fromcom- plextosimple.WorldJUrol1995;13:47—58.

[10]Valentini FA, Nelson PP, Zimmern PE, Robain G.

Detrusor contractility in women: inﬂuence of ageing and clinical conditions. Progr Urol 2016;26:425—31, http://dx.doi.org/10.1016/j.purol.2016.03.004.

[11]Choo MS, Cho SY, Han JH, Lee SH, Paick JS, Son H. The cutoffvalueofbladdervoidingefﬁciencyforpredicting sur- gical outcomes afterGreenLight HPS^TM laser photoselective vaporizationoftheprostate.JEndourol2014;28(8):969—74, http://dx.doi.org/10.1089/end.2014.0067.

[12]HsiaoSM,LinHH,KooHC.Urodynamicprognosticfactorsfor largepost-voidresidualurinevolumeafterintravesicalinjec- tionofonabotulinumtoxintypeAforoveractivebladder.Sci Rep2017;7:43753[1038/srep43753].

[13]Gammie A, Kaper M, Dorrepaal C, Kos T, Abrams P. Signs and Symptoms of Detrusor Underactivity: An Analy- sis of Clinical Presentation and Urodynamic Tests From a Large Group of Patients Undergoing Pressure Flow Studies. Eur Urol 2016;69(2):361—9, http://dx.doi.org/

10.1016/j.eururo.2015.08.014.

[14]Abarbanel J, Marcus EL. Impaired detrusor contractility incommunity-dwelling elderly presenting withlower urinary tractsymptoms.Urology2007;69:436—40.