What is the best urodynamic test to diagnose DU? A comparison and investigation of various methods
6. Nitti VW, Lefkowitz G, Ficazzola M, Dixon CM. Lower urinary tract symptoms in young men: videourodynamic findings and correlation with noninvasive measures. J Urol 2002;168:135-8. 7. Gammie A, Kaper M, Dorrepaal C, Kos T, Abrams P. Signs and symptoms of detrusor underactivity: an analysis of clinical presentation and urodynamic tests from a large group of patients undergoing pressure flow studies. EurUrol 2016;69:361-9. 8. Seong Jin Jeong, Jung Keun Lee,Kwang Mo Kim, et al. How do we diagnose detrusor underactivity? Comparison of diagnostic criteria based on an urodynamic measure, Investig Clin Urol 2017;58(4):247-254. 9. Jeong SJ, Kim HJ, Lee YJ, et al. Prevalence and clinical features of detrusor underactivity among elderly with lower urinary tract symptoms: a comparison between men and women. Korean J Urol.2012;53(5):342-348. 10. Abarbanel J,Marcus EL. Impaired detrusor contractility in community-dwelling elderly presenting with lower urinary tract symptoms. Urology. 2007;69:436-440. 11. Griffiths D. Detrusor contractility–order out of chaos. Scand J Urol Nephrol Suppl. 2004;215:93-100. 12. Gammie A, Kaper M, Dorrepaal C, Kos T, Abrams P. Signs and symptoms of detrusor underactivity: an analysis of clinical presentation and urodynamic tests from a large group of patients undergoing pressure flow studies. Eur Urol. 2016;69:361-369. 13. Rubilotta E, Balzarro M, Trabacchin N, Righettii R, D'Amico A, Blaivas JG, Antonelli A. Post-void residual urine ratio: A novel clinical approach to the post-void residual urine in the assessment of males with lower urinary tract symptoms. Investig Clin Urol. 2021; 62(4):470-476. 14. Lee KS, Song PH, Ko YH. Does uroflowmetry parameter facilitate discrimination between detrusor underactivity and bladder outlet obstruction? Investig Clin Urol. 2016;57(6):437-441. 15. Rademakers KL, van Koeveringe GA, Oelke M; FORCE Research Group, Maastricht and Hannover. Ultrasound detrusor wall thickness measurement in combination with bladder capacity can safely detect detrusor underactivity in adult men. World J Urol. 2017; 35(1):153-159. Saturday 11 March 12:00 - 12:15 ESFFU Meeting: The complex world of treatment of non-neurogenic and neurogenic bladder dysfunctions Blue Area, Room 1
pathological. Most of the definitions of DU are based on male populations.
emptying. As such, the definitions of DU do not take into account bladder functional reserve. The only parameter that could correlate with the maximum detrusor contraction force would be the isovolumetric pressure, which can be obtained by voiding while keeping the bladder neck closed with the balloon of a closed catheter. The complexity of the test and the discomfort perceived by the patient make this evaluation difficult to perform in daily clinical practice. To date, we still have not found a single and shared definition of DU. The differences between gender, the multiplicity of pathophysiological causes, and the invasiveness of the urodynamic investigation make it difficult to diagnose a DU condition with accuracy. References 1. Chapple CR, Osman NI, Birder L, et al. Terminology report from the International Continence Society (ICS) Working
Dr. Vincenzo Li Marzi Department of Urological Robotic Surgery and Renal Transplantation, Careggi University Hospital, Florence (IT) President of the Italian Society of Urodynamics (SIUD)
The following cutoffs are applied to define DU in men: • BCI (bladder contractility index, pDetQmax +5xQmax) < 100; Abrams (1999) [5] • BOOI (pDetQmax – 2xQmax)<20 and Qmax<12 mL/s; Nitti et al. (2002) [6] • BCI<100 and BOOI <20 and BVE%<90 (bladder voiding efficiency = volume voided/[volume voided + post void residual volume] × 100%) Gammie et al. (2016) [7] Jeong et al. compared the concordance of different measurements of DU in the men and found a considerable variation (5.4% - 55.8%) in the diagnosis of this condition. In particular, BCI criteria tended to overestimate DU compared with other criteria [8]. The following cutoffs are applied to define DU in women: • Pdet@Qmax ≤10cm H2O and Qmax ≤12mL/s; Jeong et al (2012) [9] • Pdet@Qmax<30cm H2O and Qmax<10mL/s; Abarbanel and Marcus (2007) [10] • Pdet@Qmax<20cm H2O and Qmax<15mL/s and BVE <90%; Griffiths (2004) [11] • Pdet@Qmax<20cm H2O+Qmax; Gammie (2016) [12] Defining the quality of female bladder emptying is very complicated. The anatomical peculiarity of the female urinary tract, a very short urethra and the absence of urethral resistance linked to the presence of the prostate, allows women to urinate even by simply relaxing the muscles of the perineal plane. Furthermore, bad micturition habits are frequent in the female population: women may use abdominal straining or postpone micturitions for many hours, with possible episodes of bladder overdistention. The absence of urethral resistances, unlike in males, makes the female bladder much more prone to decompensation in obstructive situations (eg. pelvic organ prolapse) with consequent rapid loss of contractility and risk of retentive episodes. Some non-invasive urodynamic methods have been applied for the definition of DU. A simple flowmetry may help in suspecting a condition of hypocontractility. Rubilotta et al. identified post-void residual (PVR) ratio of 40% (percentage of PVR to bladder volume) to differentiate simple obstructive conditions to obstructive conditions associated with DU [13]. Lee et al. emphasised the role of maximum flow rate (Qmax) assessment in addition to PVR: the DeltaQ parameter (Qmax – Qave) may help clinicians in differentiating between bladder outlet obstruction (BOO) and DU [14]. The ultrasound assessment of detrusor muscle thickness (DWT) was also considered as a predictive parameter of DU. Rademakers et al. identified DWT and bladder capacity as possible predictors of DU. In their study, all patients with DWT ≤ 1.23 mm and bladder capacity >445 ml had DU; the single parameter of BWT < 1.23mm was related in 78% of cases to a condition of DU [15]. Over time, several studies have been conducted on the application of the stop-test during uroflowmetry. It is possible to ask the patient to voluntarily interrupt voiding with a perineal contraction, to exercise a simple urethral compression with the fingers or with the use of cuff systems (non-invasive urodynamics). After a brief obstruction in healthy individuals, an isovolumetric intravesical contraction is expected which causes a temporary increase in flow. In males with DU, the reduced ability to increase bladder contraction power should result in a lower flow after a temporary obstruction. The perineal contraction stop test method is not recommended, as it tends to underestimate bladder contractility and can cause somatic inhibition; the use of penile cuffs can be perceived by the patient as unpleasant and make it difficult to generate a physiological flow. Therefore, these methods have not found wide application in clinical practice. One of the main limitations related to the various definitions of DU is the choice of urodynamic parameters. Most definitions take into account the Qmax and the detrusorial contraction at maximum flow (pDetQmax). The bladder performs its function by maintaining a functional reserve, so that it can be emptied even in conditions of increased resistance. Therefore, what we measure is the minimum detrusor pressure sufficient to guarantee bladder
Co-authors: Dr. Enrico Ammirati, Dr. Alessandro Giammò. Department of Neuro-Urology, CTO/Unipolar Spinal Cord Unit, AOU Città della Salute e della Scienza di Torino, Turin, Italy. On behalf of the Italian Society of Urodynamics (SIUD). The International Continence Society defines the condition of underactive bladder (UAB) as a syndrome characterised by slow urinary stream, hesitancy and straining to void, with or without a feeling of incomplete bladder emptying sometimes with storage symptoms [1]. The definition refers to a syndromic condition, i.e. a set of signs and symptoms, without a reference to urodynamic parameters. The concept of detrusor underactivity (DU), which refers to a urodynamic measurement, is different. DU refers to a low detrusor pressure or short detrusor contraction time, usually in combination with a low urine flow rate resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span measured by urodynamics [2]. This definition is clear and correctly identifies a urodynamic parameter, but open to different interpretations. No reference is made to the minimum force that the detrusor contraction should have or what its ideal duration is. No reference is made to the relationship with urethral resistance, which modulates the bladder force necessary for emptying especially in males. Lastly and importantly, a voiding phase is needed for a urodynamic diagnosis. Furthermore, DU does not refer to a single pathophysiological
Group on Underactive Bladder (UAB). NeurourolUrodyn.2018;37(8):2928-2931.
2. D'Ancona C, Haylen B, Oelke M, Abranches-Monteiro L, Arnold E, Goldman H, Hamid R, Homma Y, Marcelissen T, Rademakers K, Schizas A, Singla A, Soto I, TseV, de Wachter S, Herschorn S; Standardisation Steering Committee ICS and the ICSWorking Group on Terminology for Male Lower Urinary Tract & Pelvic Floor Symptoms and Dysfunction. The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction. NeurourolUrodyn.2019;38(2):433-477. 3. Nadir I. Osman, Christopher R. Chapple, Paul Abrams, Roger Dmochowski, Francois Haab, Victor Nitti, Heinz Koelbl, Philip van Kerrebroeck, Alan J. Wein. Detrusor Underactivity and the Underactive Bladder: A New Clinical Entity? A Review of Current Terminology, Definitions, Epidemiology, Aetiology, and Diagnosis, EurUrol2014; 65: 389 – 398. 4. Yu YD, Jeong SJ. Epidemiology of underactive bladder: Common but under researched. Investig Clin Urol. 2017;58 (Suppl 2):S68-S74. 5. Abrams P. Bladder outlet obstruction index, bladder contractility index and bladder voiding efficiency: three simple indices to define bladder voiding function. BJU Int 1999;84(1):14-5.
condition but can be related to obstruction, neurogenic bladder, urinary retention, etc.
WHY IS PSMA A KEY PHENOTYPIC BIOMARKER IN ADVANCED PROSTATE CANCER? FOR YOUR PATIENTS WITH ADVANCED PROSTATE CANCER
Similar to the relationship between overactive bladder (OAB) and detrusor overactivity (DO), not all cases of UAB correspond to the urodynamic finding of DU. Given the lack of shared cutoffs that can determine with certainty the presence of DU on urodynamic investigation, it is difficult to establish its real prevalence. According to urodynamic assessments including a pressure-flow study, the prevalence in male population is 9 – 28% < 50 years, increasing up to 48% for males older than 70 years. On the other hand, there seems to be a clear prevalence in the older age in the female population (> 65 years), with values between 12% and 45%; it seems that female patients admitted to nursing facilities have a high prevalence of mixed storage and voiding dysfunction (urodynamic DO on filling cystometry in combination with urodynamic DU on pressure-flow studies, according to the old definition: detrusor hyperactivity with impaired contractility- DHIC), the cause of both incontinence and voiding difficulties [2, 3]. DU can originate from an alteration of any of the mechanisms of the normal functioning of the micturition cycle. In some cases, the pathology is due to an alteration of the bladder innervation, afferent or efferent, as in diabetic neuropathy, Parkinson’s disease, multiple sclerosis, Guillain- Barré syndrome. It is also possible that DU is linked to myogenic factors such as, decompensated obstruction, for example. Other causes may be related to the use of drugs (e.g. antimuscarinics, antihistamines, antipsychotics), pelvic surgery, functional phenomena (e.g. Fowler’s syndrome, dysfunctional voiding), or even idiopathic such as a “normal” consequence of ageing [4]. The definition of DU and the diagnostic criteria are based on urodynamic measurements. The parameters taken into consideration are a reduced detrusor contraction strength and a poor flow, responsible for an incomplete bladder emptying. As already mentioned above, there is a lack of shared cutoffs to define the DU condition. Furthermore, there is no universally shared definition of incomplete bladder emptying, as there is no post-voiding residual value that is significantly
Prostate-specific membrane antigen (PSMA) is highly expressed in > 80 % of men with prostate cancer and can be detected by PET imaging. 1–9 PSMA is a diagnostic and potential therapeutic target, which may enable a phenotypic precision medicine approach to treating advanced prostate cancer. 1,6–11
Learn more at www.ProstateCancerandPSMA.com
PET, positron emission tomography. References
1. Hupe MC et al. Front Oncol . 2018;8:623. 2. Hope TA et al. J Nucl Med . 2017;58(12):1956–1961. 3. Pomykala KL et al. J Nucl Med . 2020;61(3):405–411. 4. Minner S et al. Prostate . 2011;71(3):281–288. 5. Bostwick DG et al. Cancer . 1998;82(11):2256–2261. 6. Hofman MS et al. Lancet . 2020;395(10231):1208–1216. 7. Hofman MS et al. Lancet Oncol . 2018;19(6):825–833. 8. Zang S et al. Oncotarget . 2017;8(7):12247–12258. 9. Calais J et al. Lancet Oncol . 2019;20(9):1286–1294. 10. Müller J et al. Eur J Nucl Med Mol Imaging . 2019;46(4):889–900. 11. Calais J et al. J Nucl Med . 2018;59(3):434–441. © 2023 Novartis Pharma AG | CH-4002, Basel, Switzerland January 2023 | AAA-NP-GL-0014-23
European Urology Today
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February/March 2023
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