British Journal of Urology (1976), 48, 383-387 0
Urodynamic Studies in the District General Hospital J. C . CRISP,N. A. GREEN and M. H. ASHKEN Department of Urology, Norfolk and Norwich Hospital, Norwich
Interest in urodynamics has increased over recent years. Many reports of academic and clinical urodynamic research have been published and these have given us a better understanding of the functional aspects of several lower urinary tract conditions (Arnold, Brown and Webster, 1974). The techniques employed give objective measurements which are helpful in evaluating the efficacy of treatment or in comparing different forms of therapy. While it is accepted that urodynamic studies are of value in research projects and clinical trials, can these investigations be justified on purely clinical grounds in a busy Urological Unit in a District General Hospital? The results of urodynamic studies done in the Urology Department of a District General Hospital are reviewed, and an assessment is made of their value in the management of a variety of common urological disorders.
Patients and Methods Equipment and Technique 2 channels of a Devices Four Channel Polygraph trace rectal and total bladder pressures from transducers via fluid-filled catheters. The 3rd channel records the subtracted or detrusor pressure. The 4th channel records urine flow rate, which is measured by a Disa mictiograph. Currently these recordings are not combined with X-rays, micturating cysto-urethrograms being performed as a separate procedure when indicated. Each investigation took 30 to 40 min and all were done by the first author, usually with I nurse in attendance. Patients and Results The results in 82 patients are presented and will be considered in the groups shown in Table I.
Group I: Wornen with Frequency, Urgency and Nocturia (35 Women) Table I1 summarises the findings in this group. The patients selected for urodynamic studies i n this group were women attending the Out-patient Department who had symptoms troublesome enough to interfere with their work or with their social life. Most of them had previously undergone some simple empirical form of treatment such as drug therapy or urethral dilatation without improvement of their symptoms. Even with the urodynamic results it was still difficult to find an effective form of treatment for each patient, and furthermore it was still not possible to predict which particular form of treatment was likely to be effective. For example, 1 patient with unstable detrusor function did not respond to various forms of drug treatment but was cured of her symptoms by an empirical Otis urethrotomy. Another patient, a 23-year-old girl with detrusor instability and nocturnal enuresis, was treated by Helmstein's bladder distension but after a few weeks her symptoms relapsed and she then responded to treatment with probanthine although previously she had failed to respond to antispasmodics.
It is interesting to note that of the 20 patients in this group with stable detrusor function 8 dated their symptoms to a previous event or operation (hysterectomy 3, anterior repair 1, D.X.T. menopause 1, appendicitis with a pelvic abscess 1 and pregnancy 2). 383
384
BRITISH JOURNAL OF UROLOGY
Table I1 Women with Frequency, Urgency and Nocturia
Table I All Patients
Urodynaniic findings Group Frequency, urgency, nocturia Incontinence? Stress? Urge “Obstructive” symptoms Post-prostatectomy symptoms Neuropathic bladder Enuresis Total
Men Women Total 0 0
35
35
I
10 0 0
3 3
0
20 7 7 3
33
49
82
20
4
Numbers
Unstable Stable Others’
I? 20 3
Total
35
10
*
1 patient had a very tight urethra which precluded catheterisation: I patient was found to have interstitial cystitis on subsequent cystoscopy; I patient had a UTI at time of testing.
Group I / : Women with Incontinence (10 patients) Of 10 women with urinary incontinence, 9 were felt on clinical grounds to have detrusor instability and were therefore investigated. Urodynamic studies showed objective evidence of instability in only 2 patients and they were treated successfully with a combination of Cetiprin and Alupent. Of the 8 patients with a stable detrusor mechanism and pure stress incontinence 4 were recommended for operative treatment, 4 were treated with more conservative measures, and in all cases symptoms were improved. Group 111: Men with “Obstructive” Symptoms (20 patientx) The indication for testing these men was doubt as to whether their symptoms were due to bladder outflow obstruction or an unstable detrusor mechanism. Table 111 summarises the findings in this group. In most of the young men there was genuine doubt as to whether their symptoms were due to bladder neck obstruction or an unstable bladder and the additional information given by the urodynamic studies was of value in arriving at the correct diagnosis. However, on careful re-questioning of the 12 patients aged between 52 and 75 years and on review of their intravenous urograms it was thought that 10 probably had obstruction and this was confirmed in 9 of them by the urodynamic studies. 8 of these 9 patients also had detrusor instability; all those who have since undergone prostatectomy have improved symptomatically. Group I V: Post-prostatectomy Symptoms ( 7 patients) All patients with post-prostatectomy symptoms were investigated and Table JV suminnrises the findings in this group. Group V: Ncwopathic Bladders (7 patients) All patients referred to the Department of Urology with suspected neuropathic bladders were investigated. There were 4 women and 3 men in this group. All the women had lower motor neurone lesions without neurological signs and with normal myelograms. 1 woman required a urinary diversion but in the light of the urodynamic findings, micturition in the other 3 has been rendered reasonably satisfactory by more conservative measures. 1 of the men was incontinent due to a cauda equina lesion following a lumbar spine injury. Catheterisation revealed a large residual urine and pressure/flow measurements during voiding showed inadequate detrusor function. Bladder emptyingwas improved following an Otis sphincterotomy although he remained
385
URODYNAMIC STUDIES IN THE DISTRICT GENERAL HOSPlTAL
Table 111 Men with “Obstructive” Symptoms Urodynamic findings * Obstruction Obstruction and alone instability i
Age-group 28-44 Age-group 52-75
1
4 8
2
12
1
Total
-7
Instability alone
Others*
Total
-7
1
2
1
8 12
4
2
20
* 2 patients could not be catheterised. Table IV Post-prostatectomy Symptoms Findings Obstruction Instability Neuropathic Normal Total
Numbers 2 2 2 1
Cause/ t reat ment 1 stricture. 1 required further T.U.R. Treated with Cetiprin L.M.N. type? cause
7
incontinent. Another of the men was a patient with multiple sclerosis who presented with acute retention. He had an enlarged prostate and urodynamic studies showed evidence both of detrusor instability and outflow obstruction; transurethral resection of his prostate was performed. Group VI: Men with Nocturnal Enuresis ( 3 patients) 2 men, aged 24 and 31 years, had unstable detrusors and in the third patient catheterisation failed.
Discussion The largest group of patients in this series is comprised of women with persistent increased frequency, urgency and nocturia, who at no time had evidence of urinary tract infection. We d o not have a simple, effective form of treatment for these patients, although their symptoms are often most unpleasant and disabling. Do urodynamic studies help in the management of these patients ? It was found that the results of urodynamic studies were of little practical help in this group. The presence or absence of detrusor instability is shown by urodynamic studies but until there is a satisfactory form of treatment for this condition these studies will be of academic interest only. Furthermore, we found that those patients with the same symptom complex namely that of frequency, urgency and nocturia and with stable detrusor function were as difficult to treat as those with unstable detrusor function.
386
BRITISH JOURNAL OF UROLOGY
As a result of our experience a rational plan of management would be to proceed to cystoscopy after the routine investigations, and cystoscopy should certainly precede urodynamic studies in order to excludeconditions such as interstitial cystitis. In the presence of a normal bladder, urethral dilatation or Otis sphincterotomy should be performed. These procedures have not worsened the symptoms in any of our patients and may give symptomatic relief, although the mechanism by which they do so is far from clear. Should symptoms remain unchanged after urethral dilatation then drugs should be prescribed and it is always worth trying several different regimes as one drug may help when others have failed. Should more aggressive forms of treatment such as Helmstein’s bladder distension, or bladder denervation procedures be contemplated, then it must be wise to perform urodynamic studies both in the pre- and postoperative periods so that the urologist knows exactly what is being treated and to have some objective evidence by which to judge the efficacy of the chosen therapy. Urodynamic studies were of value in the group of women in whom there was doubt whether their incontinence was due to urge (detrusor) or stress (sphincter) problems. All these patients had troublesome incontinence and were anxious for help, but one was reluctant to advise an operation designed for stress incontinence when detrusor instability was suspected. The findings of a stable detrusor enabled cystourethropexy to be advised in some cases and these patients did well following their operation. The patients with detrusor instability were saved an unnecessary operation and their symptoms were improved by drug therapy. The men with “obstructive” symptoms in whom detrusor instability was suspected fell into 2 age-groups. Almost all the older men had unstable bladders associated with prostatic obstruction but their symptoms were improved following prostatectomy. These patients can be assessed adequately by careful questioning, routine examination and investigations, coupled with a urine flow measurement. In the younger age-group, however, cystometrograms and pressure flow measurements are useful additional investigations and help to avoid unnecessary bladder neck incisions or resections. Urodynamic studies gave useful results in 6 of the 7 men with post-prostatectomy symptoms. The 2 men with obstruction could have been diagnosed by micturating cysto-urethrography but the findings of detrusor instability (2 patients) and neuropathic bladder (2 patients) did assist in arriving at the correct form of management. Urodynamic studies are mandatory in the investigation of the neuropathic bladder, both to confirm the diagnosis and to plan treatment. The results obtained demonstrate the presence of upper or lower motor neurone lesions and any co-existing outflow obstruction. Compared with micturating cysto-urethrography urodynamic studies give a clearer picture of detrusor function. The filling cystometrogram demonstrates whether the detrusor is unstable, or flaccid and noncontractile; also the patient’s awareness of bladder filling can be assessed. During voiding the detrusor’s ability to maintain a satisfactory and sustained contraction can be measured. These findings assisted in choosing the correct form of treatment in our patients with neuropathic bladders. The cause of nocturnal enuresis in adults who in addition have diurnal frequency and urgency is likely to be detrusor instability. This syndrome can be diagnosed by a carefully taken history and confirmation by urodynamic studies would seem unnecessary in most cases (Whiteside and Arnold, 1975).
Summary The information given by urodynamic investigations has been of practical value in clinical practice and we feel that the time and money spent has been worthwhile. The results are particularly useful in patients with neuropathic bladders, women with stress incontinence in whom detrusor instability is also suspected, young men with “obstructive” symptoms and in men with post-prostatectomy problems.
URODYNAMIC STUDIES IN THE DlSTRICT GENERAL HOSPITAL
387
Its value in the large group of women with frequency, urgency and nocturia is debatable given our present lack of satisfactory treatment for these patients. Generous grants from the East Anglian Regional Hospital Authority and the Norfolk and Norwich Institute for Medical Education enabled the Department of Urology to purchase the equipment. We should also like to thank Mr G. Carve11 of the Physics Department, Norfolk and Norwich Hospital for his invaluable help in commissioning the equipment and to Ms S. Green, Ms J. Birch and Miss F. Holdgate for their secretarial work.
References ARNOLD,E.
P., BROWN,A . D. G . and WEBSTER, J. R. (1974). Videocystography with synchronous detrusor pressure and flow rate recordings. Annals of the Royal College of’Sitrgeons of England, 55, 90-98. C. G. and ARNOLD, E. P. (1975). Persistent primary enuresis: a urodynamic assessment. British Medical WHITESIDE, Journal, 1, 364-367.
The Authors J. C. Crisp, FRCS, Surgical Registrar (now Senior Urological Registrar, Guy’s Hospital, London), N. A . Green, MS, FRCS, Consultant Urologist. M. H. Ashken, MS, FRCS, Consultant Urologist.
Urodynamic Studies in the District General Hospital J. C . CRISP,N. A. GREEN and M. H. ASHKEN Department of Urology, Norfolk and Norwich Hospital, Norwich
Interest in urodynamics has increased over recent years. Many reports of academic and clinical urodynamic research have been published and these have given us a better understanding of the functional aspects of several lower urinary tract conditions (Arnold, Brown and Webster, 1974). The techniques employed give objective measurements which are helpful in evaluating the efficacy of treatment or in comparing different forms of therapy. While it is accepted that urodynamic studies are of value in research projects and clinical trials, can these investigations be justified on purely clinical grounds in a busy Urological Unit in a District General Hospital? The results of urodynamic studies done in the Urology Department of a District General Hospital are reviewed, and an assessment is made of their value in the management of a variety of common urological disorders.
Patients and Methods Equipment and Technique 2 channels of a Devices Four Channel Polygraph trace rectal and total bladder pressures from transducers via fluid-filled catheters. The 3rd channel records the subtracted or detrusor pressure. The 4th channel records urine flow rate, which is measured by a Disa mictiograph. Currently these recordings are not combined with X-rays, micturating cysto-urethrograms being performed as a separate procedure when indicated. Each investigation took 30 to 40 min and all were done by the first author, usually with I nurse in attendance. Patients and Results The results in 82 patients are presented and will be considered in the groups shown in Table I.
Group I: Wornen with Frequency, Urgency and Nocturia (35 Women) Table I1 summarises the findings in this group. The patients selected for urodynamic studies i n this group were women attending the Out-patient Department who had symptoms troublesome enough to interfere with their work or with their social life. Most of them had previously undergone some simple empirical form of treatment such as drug therapy or urethral dilatation without improvement of their symptoms. Even with the urodynamic results it was still difficult to find an effective form of treatment for each patient, and furthermore it was still not possible to predict which particular form of treatment was likely to be effective. For example, 1 patient with unstable detrusor function did not respond to various forms of drug treatment but was cured of her symptoms by an empirical Otis urethrotomy. Another patient, a 23-year-old girl with detrusor instability and nocturnal enuresis, was treated by Helmstein's bladder distension but after a few weeks her symptoms relapsed and she then responded to treatment with probanthine although previously she had failed to respond to antispasmodics.
It is interesting to note that of the 20 patients in this group with stable detrusor function 8 dated their symptoms to a previous event or operation (hysterectomy 3, anterior repair 1, D.X.T. menopause 1, appendicitis with a pelvic abscess 1 and pregnancy 2). 383
384
BRITISH JOURNAL OF UROLOGY
Table I1 Women with Frequency, Urgency and Nocturia
Table I All Patients
Urodynaniic findings Group Frequency, urgency, nocturia Incontinence? Stress? Urge “Obstructive” symptoms Post-prostatectomy symptoms Neuropathic bladder Enuresis Total
Men Women Total 0 0
35
35
I
10 0 0
3 3
0
20 7 7 3
33
49
82
20
4
Numbers
Unstable Stable Others’
I? 20 3
Total
35
10
*
1 patient had a very tight urethra which precluded catheterisation: I patient was found to have interstitial cystitis on subsequent cystoscopy; I patient had a UTI at time of testing.
Group I / : Women with Incontinence (10 patients) Of 10 women with urinary incontinence, 9 were felt on clinical grounds to have detrusor instability and were therefore investigated. Urodynamic studies showed objective evidence of instability in only 2 patients and they were treated successfully with a combination of Cetiprin and Alupent. Of the 8 patients with a stable detrusor mechanism and pure stress incontinence 4 were recommended for operative treatment, 4 were treated with more conservative measures, and in all cases symptoms were improved. Group 111: Men with “Obstructive” Symptoms (20 patientx) The indication for testing these men was doubt as to whether their symptoms were due to bladder outflow obstruction or an unstable detrusor mechanism. Table 111 summarises the findings in this group. In most of the young men there was genuine doubt as to whether their symptoms were due to bladder neck obstruction or an unstable bladder and the additional information given by the urodynamic studies was of value in arriving at the correct diagnosis. However, on careful re-questioning of the 12 patients aged between 52 and 75 years and on review of their intravenous urograms it was thought that 10 probably had obstruction and this was confirmed in 9 of them by the urodynamic studies. 8 of these 9 patients also had detrusor instability; all those who have since undergone prostatectomy have improved symptomatically. Group I V: Post-prostatectomy Symptoms ( 7 patients) All patients with post-prostatectomy symptoms were investigated and Table JV suminnrises the findings in this group. Group V: Ncwopathic Bladders (7 patients) All patients referred to the Department of Urology with suspected neuropathic bladders were investigated. There were 4 women and 3 men in this group. All the women had lower motor neurone lesions without neurological signs and with normal myelograms. 1 woman required a urinary diversion but in the light of the urodynamic findings, micturition in the other 3 has been rendered reasonably satisfactory by more conservative measures. 1 of the men was incontinent due to a cauda equina lesion following a lumbar spine injury. Catheterisation revealed a large residual urine and pressure/flow measurements during voiding showed inadequate detrusor function. Bladder emptyingwas improved following an Otis sphincterotomy although he remained
385
URODYNAMIC STUDIES IN THE DISTRICT GENERAL HOSPlTAL
Table 111 Men with “Obstructive” Symptoms Urodynamic findings * Obstruction Obstruction and alone instability i
Age-group 28-44 Age-group 52-75
1
4 8
2
12
1
Total
-7
Instability alone
Others*
Total
-7
1
2
1
8 12
4
2
20
* 2 patients could not be catheterised. Table IV Post-prostatectomy Symptoms Findings Obstruction Instability Neuropathic Normal Total
Numbers 2 2 2 1
Cause/ t reat ment 1 stricture. 1 required further T.U.R. Treated with Cetiprin L.M.N. type? cause
7
incontinent. Another of the men was a patient with multiple sclerosis who presented with acute retention. He had an enlarged prostate and urodynamic studies showed evidence both of detrusor instability and outflow obstruction; transurethral resection of his prostate was performed. Group VI: Men with Nocturnal Enuresis ( 3 patients) 2 men, aged 24 and 31 years, had unstable detrusors and in the third patient catheterisation failed.
Discussion The largest group of patients in this series is comprised of women with persistent increased frequency, urgency and nocturia, who at no time had evidence of urinary tract infection. We d o not have a simple, effective form of treatment for these patients, although their symptoms are often most unpleasant and disabling. Do urodynamic studies help in the management of these patients ? It was found that the results of urodynamic studies were of little practical help in this group. The presence or absence of detrusor instability is shown by urodynamic studies but until there is a satisfactory form of treatment for this condition these studies will be of academic interest only. Furthermore, we found that those patients with the same symptom complex namely that of frequency, urgency and nocturia and with stable detrusor function were as difficult to treat as those with unstable detrusor function.
386
BRITISH JOURNAL OF UROLOGY
As a result of our experience a rational plan of management would be to proceed to cystoscopy after the routine investigations, and cystoscopy should certainly precede urodynamic studies in order to excludeconditions such as interstitial cystitis. In the presence of a normal bladder, urethral dilatation or Otis sphincterotomy should be performed. These procedures have not worsened the symptoms in any of our patients and may give symptomatic relief, although the mechanism by which they do so is far from clear. Should symptoms remain unchanged after urethral dilatation then drugs should be prescribed and it is always worth trying several different regimes as one drug may help when others have failed. Should more aggressive forms of treatment such as Helmstein’s bladder distension, or bladder denervation procedures be contemplated, then it must be wise to perform urodynamic studies both in the pre- and postoperative periods so that the urologist knows exactly what is being treated and to have some objective evidence by which to judge the efficacy of the chosen therapy. Urodynamic studies were of value in the group of women in whom there was doubt whether their incontinence was due to urge (detrusor) or stress (sphincter) problems. All these patients had troublesome incontinence and were anxious for help, but one was reluctant to advise an operation designed for stress incontinence when detrusor instability was suspected. The findings of a stable detrusor enabled cystourethropexy to be advised in some cases and these patients did well following their operation. The patients with detrusor instability were saved an unnecessary operation and their symptoms were improved by drug therapy. The men with “obstructive” symptoms in whom detrusor instability was suspected fell into 2 age-groups. Almost all the older men had unstable bladders associated with prostatic obstruction but their symptoms were improved following prostatectomy. These patients can be assessed adequately by careful questioning, routine examination and investigations, coupled with a urine flow measurement. In the younger age-group, however, cystometrograms and pressure flow measurements are useful additional investigations and help to avoid unnecessary bladder neck incisions or resections. Urodynamic studies gave useful results in 6 of the 7 men with post-prostatectomy symptoms. The 2 men with obstruction could have been diagnosed by micturating cysto-urethrography but the findings of detrusor instability (2 patients) and neuropathic bladder (2 patients) did assist in arriving at the correct form of management. Urodynamic studies are mandatory in the investigation of the neuropathic bladder, both to confirm the diagnosis and to plan treatment. The results obtained demonstrate the presence of upper or lower motor neurone lesions and any co-existing outflow obstruction. Compared with micturating cysto-urethrography urodynamic studies give a clearer picture of detrusor function. The filling cystometrogram demonstrates whether the detrusor is unstable, or flaccid and noncontractile; also the patient’s awareness of bladder filling can be assessed. During voiding the detrusor’s ability to maintain a satisfactory and sustained contraction can be measured. These findings assisted in choosing the correct form of treatment in our patients with neuropathic bladders. The cause of nocturnal enuresis in adults who in addition have diurnal frequency and urgency is likely to be detrusor instability. This syndrome can be diagnosed by a carefully taken history and confirmation by urodynamic studies would seem unnecessary in most cases (Whiteside and Arnold, 1975).
Summary The information given by urodynamic investigations has been of practical value in clinical practice and we feel that the time and money spent has been worthwhile. The results are particularly useful in patients with neuropathic bladders, women with stress incontinence in whom detrusor instability is also suspected, young men with “obstructive” symptoms and in men with post-prostatectomy problems.
URODYNAMIC STUDIES IN THE DlSTRICT GENERAL HOSPITAL
387
Its value in the large group of women with frequency, urgency and nocturia is debatable given our present lack of satisfactory treatment for these patients. Generous grants from the East Anglian Regional Hospital Authority and the Norfolk and Norwich Institute for Medical Education enabled the Department of Urology to purchase the equipment. We should also like to thank Mr G. Carve11 of the Physics Department, Norfolk and Norwich Hospital for his invaluable help in commissioning the equipment and to Ms S. Green, Ms J. Birch and Miss F. Holdgate for their secretarial work.
References ARNOLD,E.
P., BROWN,A . D. G . and WEBSTER, J. R. (1974). Videocystography with synchronous detrusor pressure and flow rate recordings. Annals of the Royal College of’Sitrgeons of England, 55, 90-98. C. G. and ARNOLD, E. P. (1975). Persistent primary enuresis: a urodynamic assessment. British Medical WHITESIDE, Journal, 1, 364-367.
The Authors J. C. Crisp, FRCS, Surgical Registrar (now Senior Urological Registrar, Guy’s Hospital, London), N. A . Green, MS, FRCS, Consultant Urologist. M. H. Ashken, MS, FRCS, Consultant Urologist.
