Johnson F. Tsui

Pad Count is a Poor Measure of the Severity of Urinary Incontinence

PURPOSE We analyzed the correlation between pad use, as determined by objective pad count, and the severity of urinary incontinence, as measured by pad weight. MATERIALS AND METHODS We performed a retrospective study of consecutive incontinent patients who wore pads on a daily basis and were instructed to complete a 24-hour pad test. They were told to use the usual pads, change them as usual and place each in a separate plastic bag the day before the scheduled appointment. All pads were weighed and total urine loss was calculated by subtracting dry pad weight from wet pad weight, assuming that a 1 gm weight increase was equivalent to 1 ml of urine loss. The number of pads was correlated to pad weight using the Spearman rank correlation coefficient due to the nonparametric nature of the data. RESULTS The 116 patients included 51 men 39 to 89 years old (mean age 66) and 65 women 27 to 95 years old (mean age 72). When comparing the number of pads used to the gm of urine lost, the Spearman ρ was 0.26 (p=0.005) in the total cohort, and 0.40 and 0.26 (each p<0.05) in males and females, respectively. CONCLUSIONS There was little correlation between the number of pads used and the severity of urinary incontinence (r=0.26). These data suggest that pad count should not be used as an objective measure of incontinence severity. Instead, pad weight on a 24-hour pad test should be used.

Management of Urethral Stricture in Women

PURPOSE We describe the diagnosis and treatment of urethral strictures in women. MATERIALS AND METHODS We retrospectively identified female urethral strictures from 1998 to 2010. Study inclusion criteria were 1) clinical diagnosis of stricture, 2) stricture seen on cystoscopy, 3) urethral obstruction on videourodynamics according to the Blaivas-Groutz nomogram and/or 4) urethral caliber less than 17Fr. Postoperative recurrence was defined by the preoperative criteria. RESULTS We identified 17 women with a mean age of 62 years (range 32 to 91) with stricture. Stricture was idiopathic in 8 patients, iatrogenic in 6, traumatic in 2 and associated with a urethral diverticulum in 1. Videourodynamics could not be done in 3 women due to complete obliteration of the urethra. Ten of 14 patients satisfied videourodynamic criteria for obstruction and 4 had impaired detrusor contractility. Nine women underwent vaginal flap urethroplasty, including 5 who also had a pubovaginal sling and 1 who had a Martius flap. One patient received a buccal mucosal graft as primary treatment after initial dilation. There was no recurrence at a minimum 1-year followup but 2 strictures recurred 5½ and 6 years postoperatively, respectively. These 2 women received a buccal mucosal graft and were stricture free 12 to 15 months postoperatively. Of 17 patients initially treated with urethral dilation recurrence developed in 16, requiring repeat dilations until urethroplasty was performed. CONCLUSIONS In select women vaginal flap urethroplasty and buccal mucosal graft have high success rates, including 100% at 1 year and 78% at 5 years. Urethral dilation has a 6% success rate. Long-term followup is mandatory. Treatment should be individualized.

Reliability and validity of the overactive bladder symptom score in spanish (OABSS-S)†‡

To validate the Spanish translation of the Overactive Bladder Symptom Score (OABSS) questionnaire.

Outcomes of reduction cystoplasty in men with impaired detrusor contractility.

OBJECTIVE To report surgical outcomes in patients with impaired detrusor contractility (IDC) treated with reduction cystoplasty (RC). METHODS This was a retrospective study of consecutive patients with IDC who underwent RC. IDC was defined as a bladder contractility index of <100 and/or a detrusor contraction of insufficient duration resulting in a postvoid residual volume (PVR) >600 mL. Bladder outlet obstruction was defined by a bladder outlet obstruction index (BOOI) >40. All patients had preoperative International Prostate Symptom Score, maximum uroflow (Qmax), PVR, bladder diary, videourodynamics, and cystoscopy. Patients with prostatic obstruction underwent synchronous open prostatectomy. Postoperative Qmax, PVR, need for clean intermittent catheterization (CIC), and Patient Global Impression of Improvement (PGII) score were obtained. Follow-up was at 3 months, 1 year, and yearly thereafter. RESULTS Eight men met inclusion criteria (mean age, 60; range, 43-75 years). Preoperatively, 3 of 8 patients (37.5%) had moderate-sized bladder diverticula, 4 of 8 (50%) had a bladder contractility index <100, and 6 of 8 (75%) had a BOOI <40. Two patients (25%) fulfilled criteria for bladder outlet obstruction (BOOI, 67 and 72). Three (37.5%) underwent synchronous bladder diverticulectomy, and 3 (37.5%) underwent suprapubic prostatectomy. All patients were available for follow-up at 1 year. Seven of 8 (88%) had a successful outcome (PGII ≤2). One patient was unchanged (PGII, 4) and still needed CIC. CONCLUSION All but 1 patient who met specific criteria for RC had excellent outcomes after surgery based on the PGII, PVR, Qmax, and need for CIC. RC is a viable option for properly selected patients with IDC.

Determinants of nocturia severity in men, derived from frequency-volume charts

Abstract Objective. Nocturia may be characterized by indices derived from the frequency–volume chart (FVC). The objective of this study was to determine how these parameters relate to the severity of nocturia in men with and without lower urinary tract symptoms (LUTS). Materials and methods. A retrospective analysis of FVCs was performed in two cohorts of men: those presenting with LUTS in a New York ambulatory urology clinic and those from the longitudinal population-based Krimpen study. Nocturnal urine volume (NUV), nocturia index (Ni), nocturnal polyuria index (NPi), nocturnal maximal voided volume (nMVV) and sleep duration were derived from FVCs. Comparisons were made using Spearman’s rank correlation coefficient between actual number of nightly voids (ANV) and the other diary parameters. Results. Eighty-eight consecutive men who presented with LUTS completed a 24 h FVC [median age 70 years, interquartile range (IQR) 64.5–74.5, median ANV 2, IQR 1.5–4]. Nocturnal voiding frequency and volume were analyzed in 1082 community-dwelling men (median age 61 years, IQR 56.1–66.4, range 49.4–78.2; median ANV 1.5, IQR 1.0–2.0, range 0–4.5). Both cohorts demonstrated strong correlations between nocturia severity (represented as ANV) and Ni (0.797, 0.658 for cohorts 1 and 2, respectively). There were moderate correlations between nocturia severity and NPi (0.545, 0.394), NUV (0.463, 0.432) and sleep duration (0.306, 0.272). The nMVV correlated poorly with nocturia severity (0.159, 0.146). Conclusions. Treatment of nocturia should aim to match nocturnal urine production with bladder capacity. Given the lack of known effective pharmacotherapy for low bladder volume, the first attempt nocturia treatment could focus on volume reduction.

Urogynecological conditions associated with overactive bladder symptoms in women

INTRODUCTION Overactive bladder symptoms (OAB) affect 9-43% of women and are associated with underlying disorders, including pelvic organ prolapse (POP) and stress urinary incontinence (SUI). The aim of this study is to identify urogynecological conditions associated with OAB symptoms. METHODS This prospective, institutional review board-approved study included women referred to a tertiary centre with lower urinary tract symptoms (LUTS). All women completed the self-administered OAB questionnaire (OABSS). Those with an OABSS ≥8, the cutoff, were considered to have OAB symptoms. Patients underwent a history and physical examination (including Baden-Walker prolapse grading and stress test), 24-hour voiding diary, pad test (for urinary incontinence), urinalysis, and uroflow with post-void residual volume. Patients were classified clinically into the following: idiopathic OAB, SUI, POP, bladder outlet obstruction (BOO) neurogenic bladder (NGB), recurrent urinary tract infection (UTI), and miscellaneous. RESULTS In total, 148 women met the inclusion criteria with a mean age of 67 years. Only 27% had no comorbid conditions and were considered idiopathic OAB. Associated urogynecological conditions included SUI in 37%, POP in 26%, miscellaneous conditions in 18%, recurrent UTI in 11%, NGB in 9%, and BOO in 8%. Some patients met criteria for more than one category, thus the total is greater than 100%. CONCLUSIONS In a tertiary care setting, a significant proportion of women with OAB symptoms have underlying conditions that may cause or contribute to their symptoms. Appropriate evaluation is desirable to enhance our understanding of the relationship of these conditions to the diagnosis, treatment, outcomes, and pathophysiology of OAB.

Relationship between voided volume and the urge to void among patients with lower urinary tract symptoms

Abstract Objective.The aim of this study was to explore the relationship between voided volume (VV) and urge to void among patients with lower urinary tract symptoms. Material and methods. Consecutive adult patients (aged 23–90 years) were enrolled, and completed a 24 h bladder diary and the Urgency Perception Scale (UPS). Patients were categorized as urgency or non-urgency based on the Overactive Bladder Symptom Score. The relationship between UPS and VV (based on the bladder diary) was analyzed by Spearman’s rho and proportional odds model. Results. In total, 1265 micturitions were evaluated in 117 individuals (41 men, 76 women; 56 individuals in the urgency and 61 in the non-urgency group). The mean (± SD) VV and UPS were 192 ± 127 ml and 2.4 ± 1.2 ml in the urgency group and 173 ± 124 ml and 1.7 ± 1.1 ml in the non-urgency group, respectively. Spearman’s rho (between UPS and VV) was 0.21 [95% confidence interval (CI) 0.13–029, p < 0.001] for the urgency group, 0.32 (95% CI 0.25–0.39, p < 0.001) for the non-urgency group, and 0.28 (95% CI 0.23–0.33, p < 0.001) for the total cohort. Urgency patients had higher UPS [odds ratio (OR) 3.1, 95% CI 2.5–3.8]. Overall, each additional 50 ml VV increased the odds of having a higher UPS with OR 1.2 (95% CI 1.2–1.3). The relationship between VV and UPS score was similar in both groups (p = 0.548 for interaction). Conclusion. Although urgency patients void with a higher UPS score, among both urgency and non-urgency patients there is only a weak correlation between VV and the urge to void. This suggests that there are factors other than VV that cause the urge to void.

Nocturia and Overactive Bladder

The relationship between overactive bladder (OAB) and nocturia is not well understood. Research has been hampered because of difficulties presented by the definitions of both conditions as well as the lack of methods for discerning the difference between voiding during sleep hours because of awakening for some other reason and voiding after being awakened by urgency, the cardinal symptom of OAB. Notwithstanding these difficulties, it seems clear that OAB is a major risk factor in both men and women for having nocturia, but the converse is not true – only about one-third of nocturics have OAB.

Nocturia in the Elderly

Nocturia is a part of life for most older persons, especially men, nearly 90% of whom experience at least one episode of nighttime voiding [1]. It is often cited as one of the most bothersome of lower urinary tract symptoms (LUTS) [2, 3]. Unlike the other common LUTS, nocturia can cause significant morbidity and even mortality for elderly persons.