Veronica Triaca, Christian O. Twiss, Larissa V. Rodriguez, Shlomo Raz

UCLA Medical Center, Los Angeles, CA

Introduction and Objective: Symptoms of voiding dysfunction are common in patients with pelvic organ prolapse. In patients with grade 4 cystocele we have previously reported presenting symptoms to be obstructive voiding (OVS) in 44%.There is also evidence that the incidence and severity of these complaints increases with age. The value of urodynamic evaluation in patients with grade 4 cystocele is not yet well defined. The purpose of this study was to correlate the subjective voiding dysfunction symptoms with urodynamic (UDS) findings in patients with grade 4 cystocele and OVS.

Methods: We retrospectively evaluated a small subset of 59 patients who presented with urinary symptoms and were evaluated with videourodynamics between July 2005 and September 2006. These patients were all found to have Grade 4 cystocele on VCUG and physical examination. All patients underwent clinical evaluation, videourodynamics and cystoscopy. We looked at the following three criteria: 1) post-void residuals as determined on initial catheterization prior to UDS evaluation; 2) Obstruction using a definition of urodynamic obstruction as detrussor pressure of more than 25 cm H₂0 and a Qmax less than 10ml/s (Urology. 2004 Oct;64(4):675-9); and 3). Bladder-neck obstruction or kinking defined as less than 45-degree angle between the bladder neck and the urethra on lateral cystography films between rest and straining with the patient in the standing position.

Results: Fifty-nine patients were evaluated during the study period. Of these 5 (8.5%) presented with SUI; 17 (28.8%) presented with UI; 6 (10.2%) presented with MUI and 30 (50.5%) presented with OVS as their chief complaint.

The mean post-void residual for those patients presenting with symptoms other than obstruction was 106.5 cc. Of those patients with OVS, the mean post void residual was 178.3 cc (p<0.05).

Using a detrusor pressure of more than 25 cm H₂0 and a Qmax less than 10ml/s we identified 13 of 18 patients who voided for the study that were obstructed on urodynamics (22%). Of those 30 presenting with OVS, only 8 had urodynamic evidence of obstruction (26.7%). Five patients were found to be obstructed, but did not present with OVS (16.7%).

Anatomic findings of bladder neck obstruction were also examined. Of 59 patients in the cohort, 41 patients (69.5%) had radiographic evidence of bladder-neck kinking. Of those patients presenting with obstructive voiding symptoms, 100% had evidence of bladder-neck kinking on strain. In addition, of those patients that were obstructed by pressure flow measurements, 11 of 13 (84.6%) also had radiographic evidence of bladder-neck kinking. Of those that were unable to void for the study, but generated detrussor pressures, 57.1% (4) also had evidence of bladder-neck kinking. Of the 30 patients that presented with OVS, 27 had evidence of bladder-neck kinking on lateral cystography (90%).

Conclusions: Patients with grade 4 cystocele often present with subjective voiding dysfunction. In this study, the most common presenting symptom was obstruction. In this cohort of patients, it was difficult to objectively demonstrate findings of obstruction on urodynamic evaluation since only a small portion of patients were able to void. However, this study showed that there is a 100% correlation between OVS and bladder-neck kinking, yet only 27% of OVS patients met criteria for obstruction in pressure-flow study. Because the primary mechanism of obstruction appears to be bladder-neck kinking, this renders pressure-flow measurements unreliable assessments of obstruction. Further, we found a significant difference in post-void residuals in patients presenting with OVS when compared to those presenting with other symptoms. Post-void residuals and lateral cystography appear to be sensitive determinants of obstruction in patients with grade 4 cystocele presenting with OVS. The role of UDS in patients with grade 4 cystocele remains to be defined.

UroToday.com Coverage of SUFU 2007

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