Intravesical Residual Urine of Patients with Benign Prostate Hyperplasia, Sonography Accuracy
Samad Hazhir Karzar,
Nazanin Hazhir Karzar
Measurement of intravesical residual urine is experimentally a diagnostic, therapeutic and follow-up criterion in patients with benign prostate hyperplasia. The study aims at evaluating sonography accuracy in measuring intravesical residual urine in comparison with standard and accurate way of measurement through bladder catheterization. The study was conducted on 60 patients hospitalized for benign prostate hyperplasia. Mean age of the patients was 67.10±8.33 years. In all patients with full bladder and after urination, the post void residue was initially measured by sonography at supine position and then immediately through bladder catheterization. This study evaluated 60 patients with mean age of 67.10±8.33 years. The difference between measuring through sonography and catheterization was 7.89±0.86, 14.46±1.87 and 32.73±2.99 mL in postvoid residue less than 50, 51-100 and more than 100 mL, respectively. In patients with benign prostate hyperplasia, transabdominal sonography is a non-invasive method to determine postvoid residue amount.
Received: November 06, 2012;
Accepted: February 04, 2013;
Published: March 09, 2013
Significant intravesical Postvoid Reside (PVR) is one of the manifestations
of Benign Prostate Hyperplasia (BPH). Determining PVR volume is one of the routine
important evaluations in BPH and serial measurement may indicate to clinical
progress (Park et al., 2012; Zabkowski,
2012). Determination of PVR through bladder catheterization is regarded
a standard technique but it is associated with infection of the urinary system
and injury of urinary tract. Additionally, it may bear some degrees of error
in some cases (Dell'Atti, 2012; Elmansy
et al., 2012). Nevertheless, it carries the risk of infection and
trauma to the urethra, In addition, it has been reported to be inaccurate to
some extent (Hossain et al., 2012). Ultrasonogram
is useful for general screening at the urinary tract. It is the examination
of choice in defining renal cysts, detecting renal masses, kidney size and contour,
diagnosing and following hydronephrosis and evaluating the bladder by measuring
its maximum cystomatric capacity, post voidal residue, wall thickness, any mass
lesion and vesicle calculus. It is a useful adjunct in demonstrating renal calculi
(Chen et al., 2012; Kim
et al., 2012). Non-invasive urine volume measurement is an important
tool in the measuring of intravesical residual urine. Sonography is used as
a quick and noninvasive method to evaluate PVR volume instead of bladder catheterization.
Although some take care in interpretation of PVR measurement through transabdominal
ultrasonography (Homma et al., 2011; Zhu
et al., 2011) , this study aimed at determining PVR volume in BPH
patients which is in contrary to this mental background.
MATERIALS AND METHODS
This analytical study evaluated 60 patients with BPH hospitalized at urology
ward of Sina hospital from Aug 2011 to Aug 2012. This study was approved by
ethic committee of Tabriz University of Medical Sciences. Written consent was
obtained from all the patients. Two patients were excluded from the study due
to tract stenosis and impossibility of bladder catheterization. Also, those
patients with permanent catheter in their bladder due to acute urinary retention
or neurogenic disorders did not enter the study. Patients with sonographic evidences
of upper urinary system dilatation and consumption of bladder diuretic were
excluded from the present study. In every patient, urine volume was initially
measured with full bladder and supine position through transabdominal sonography.
Then, the patients were asked to empty their bladder through urinating for two
times. Then, sonography was repeated to measure and record PVR volume. It was
described to the patients that mild bladder catheterization will be used to
measure their postvoid residue to exactly and completely evaluated the conditions
before operation. After informing the patients and completely satisfying them,
a Nelaton catheter (No.18) was inserted into the bladder. The postvoid residual
(if any) were evacuated and measured using a scaled container. The measured
PVR varied between zero and 809 mL (averagely 83.55±16.63) and zero and
845 mL (averagely 98.19±17.85) in sonography and catheter methods, respectively.
The study data was analyzed with SPSS 16 software. Mc Nemar and Kruskal-wallis
statistical tests were used to study error values of the postvoid residue measured
through sonography. The p<0.05 was regarded as meaningful.
Mean age of the patients was 67.10±8.33 years. PVR measured through
sonography and bladder catheterization were compared. Results of PVR measurement
through sonography and bladder catheterization revealed that PVR measured through
sonography is equal or relatively less than standard bladder catheterization
method in 88% of cases (Table 1). To accurately analyze the
obtained data, the patients were divided into three groups of 0-50, 51-100 and
more than 100 mL considering PVR volume. It was revealed that there is a meaningful
difference between three groups considering mean measurement error (p<0.001).
In other words, the less the PVR, the less the measurement error will be (Table
2). Sonography with error of about 7.89±0.86, 14.46±1.87 and
32.73±2.99 mL in volumes less than 50, between 51 and 100 and more than
100 mL may determine PVR. The Mc Nemar statistical test confirms the above findings
(Table 3). Since PVR>100 mL is regarded as one of criteria
to make decisions about BPH diagnosis and treatment and paying more attention
to outcomes resulted from statistical test, it can be concluded that sonography
averagely demonstrates PVR less than (32.73±2.99) the real value in PVR
volumes>100 mL. regression test indicated to a positive meaningful relationship
between PVR values measured through sonography and bladder catheterization (p<0.001,
r = 0.997). Determination coefficient between PVR values measured through sonography
and bladder catheterization is 0.94. Regression model demonstrates general relationship
between PVR values measured through sonography and bladder catheterization:
PVR (with sonography) *1.069+8.85 = PVR (with catheter), i.e., it is possible
to predict accurate value of PVR obtained with bladder catheterization using
the above mathematical model and considering PVR measured through sonography.
|| PVR values measured through sonography
||Comparison of PVR measurement error in different postvoid
||Comparison measurement accuracy of postvoid residue in two
methods of sonography and bladder catheterization
Intravesical residual urine is one of the most common complaints in the elderly
men and benign prostate obstruction is one of the most frequent causes. Pressure
flow study has been recommended before surgical treatment of prostate enlargement
by many authors. Searching for new accurate methods that could substitute the
gold standard pressure-flow study demonstrates the need for lowering costs,
expanding accessibility and relieving patient discomfort (Dicuio
et al., 2010; Lee et al., 2010).
Clinical data such as IPSS, post voiding residue and flowmetry have been previously
demonstrated to correlate mostly to lower urinary tract functional status rather
than mechanical obstruction itself. Therefore, noninvasive measurements of the
prostate intend to delineate a morpho-functional correlation in order to orient
conduct towards LUTS secondary to benign prostate obstruction (Park
et al., 2010; Shinbo et al., 2010).
Significant PVR may result in symptoms including frequent urination, enuresis,
urinary incontinence of over flow type and recursive urinary infections. PVR
measurement is important in denying neurologic disorders or occlusive diseases
(El-Husseiny and Buchholz, 2011; Seo
et al., 2011). PVR measurement will be helpful in primary evaluation
and control of clinical progress process of BPH patients (Takada
et al., 2011). Considering ever-increasing prevalence of chemotherapy
in BPH patients, it is more necessary to use a quick and noninvasive way with
sufficient accuracy (Foo, 2010). During recent years,
PVR is measured through bladder catheterization which is regarded as an accurate
and standard method. However, bladder catheterization is associated with infection
and urinary tract trauma risk (Wang et al., 2011;
Wang and Foo, 2010). During the last three decades,
sonography has been used as an alternative method to determine bladder urine
volume. Although several studies have been conducted in this regard, measurement
accuracy of PVR through sonography in comparison with conventional and standard
way of bladder catheterization is still controversial (Choi
et al., 2010; Foo, 2010). Findings of the
present study are considered especially when PVR volume used in clinical decision
making for treatment equals 100 mL or exceeds it. Intravesical protrusion seems
to corroborate with urinary obstruction through a valve ball mechanism,
in which the prostate's lateral and medium lobes interfere on the complete opening
of the vesical neck while the patient urinates. According to this mechanism
and based on the present study, it was demonstrated that the intravesical protrusion
of the prostate relates not only to the urinary obstruction itself, but it also
provides information concerning the severity of obstruction. It has been demonstrated
that the greater the IPP, the higher BOOI. Still significant, but to a lesser
extent, results of prostatic volume obtained through ultrasound and PSA also
related to the degree of obstruction (Han et al.,
According to the results, it seems that conventional transabdominal sonography is a healthy, quick and reliable way to evaluate PVR in BPH patients. Considering ever-increasing intention to use chemotherapy for BPH, sonography can be used frequently and repeatedly, even in clinic, to control the disease progress and its treatment without risk of infection and urinary tract trauma.
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