Cystometrical Sensory Data from a Normal Population: Comparison of Two Groups of Young Healthy Volunteers Examined with 5 Years Interval

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European Urology European Urology 42 2002) 34±38 Cystometrical Sensory Data from a Normal Population: Comparison of Two Groups of Young Healthy Volunteers Examined with 5 Years Interval J.

1 European Urology European Urology ) 34±38 Cystometrical Sensory Data from a Normal Population: Comparison of Two Groups of Young Healthy Volunteers Examined with 5 Years Interval J.J. Wyndaele *, S. De Wachter Department of Urology, University Antwerpen, Antwerpen, Belgium Accepted 15 April 2002 Abstract Objective: To describe the pattern of sensations reported during standardized cystometry in a group of healthy young volunteers and compare them with a group examined 5 years before. Methods: A group of 50 young healthy volunteers without any symptoms or history reported the sensations they felt during cystometry. These results were compared with those of another group of 38 young healthy volunteers examined in the same lab in 1995 by another investigator. Results: All participants perceived a rst sensation of bladder lling, rst desire to void and strong desire to void. Each sensation was easily distinguishable from the others. The volumes at which these sensations came up varied widely. The ratio between volumes at consecutive sensations and at full bladder was fairly constant. All but two parameters were not signi cantly different from those found in Conclusions: Our data give additional weight to previous ndings that there exists a normal pattern of sensations reported during cystometric bladder lling. This sensory pattern probably corresponds with speci c physiological mechanisms as suggested before. Deviations from this pattern indicate or illustrate pathology. # 2002 Elsevier Science B.V. All rights reserved. Keywords: Adult; Urodynamics; Healthy; Urinary bladder; Cystometry; Pressure/ ow; Sensation 1. Introduction Urodynamic data in normal healthy volunteers are determined to understand the normal function of the lower urinary tract and to improve the interpretation of studies done in patients with different pathological conditions. It is however, uncertain how reliable the conclusions from investigations in groups of normal volunteers are. In order to evaluate normality in bladder lling sensation properly, we conducted standardized cystometry in a group of symptom free, healthy young volunteers. The results were compared with those of another group healthy young people studied 5 years previously with the same methodology. * Corresponding author. Present Address:Department of Urology, UZA, 10 Wilrijkstraat, B 2650 Edegem, Belgium. Tel ; Fax: address: jean-jacques.wyndaele@uza.be J.J. Wyndaele). 2. Materials and methods In 1999 we published on the results of 38 healthy volunteers, 10 women and 28 men [1] examined in 1995±1996. In 2000, we performed a second study. After approval of the university ethical committee the prospective study was opened to volunteers. By authority of the ethical committee students from the medical faculty were not permitted to participate in order to eliminate con ict of interest and possible bias. Inclusion criteria were complete absence of urological, gynaecological, sexual, neurological and anorectal history, and symptoms or signs of disease. All volunteers were given a full explanation about the study and the tests it involved. A total of 50 volunteers were included, mean age 21 from 18 to 30). They were 18 men and 32 women. The participants were asked to present with a full bladder and normal desire to void. After a free ow study the volunteers were positioned on a tilting radiological table in the supine position. Residual urine was measured with catheterization and a sample taken for urine analysis and culture. A three-way 8 F cystometry catheter was introduced transurethrally using non-anaesthetic lubricant. Cystometry was performed with six channel urodynamic equipment. All pressure lines were uid lled and connected to external pressure transducers /02/$ ± see front matter # 2002 Elsevier Science B.V. All rights reserved. PII:S )00221-X

2 J.J. Wyndaele, S. De Wachter / European Urology ) 34±38 35 One lumen of the cystometry catheter was used for bladder pressure measurement, one for measurement of urethral pressure at the highest pressure point, and one for bladder lling and emptying. Abdominal pressure was measured with an 8 F uid lled balloon catheter introduced at least 10 cm in the rectum. The catheters were xed on the body surface with tape. The volunteers were then tilted into the sitting position. Continuous bladder lling was done with sterile saline at body temperature until maximum cystometric capacity was reached. Detrusor activity was noted. The volunteers were asked to report immediately all sensations they felt during bladder lling and the changes in sensation. The moments were noticed on the trace and the volunteers were asked to describe the sensation, locate it, grade it and if they recognized it as a sensation from their normal life. Micturition was done sitting for both sexes in order to avoid movement of the catheters. The residual volume was evacuated, measured and the catheter removed. A solution of 5.6 g fosfomycine was given orally as prophylaxis. The recommendations on techniques and terminology by the International Continence Society were used [2]. The lling speed of the bladder was 30 ml/min. The study was performed by the second author who did not participate in the previous study. Data from both studies were introduced into the SPSS PC program for analysis. Non-parametric methods were used. Data are reported as range and S.D., p < 0:05 is considered statistically signi cant. 3. Results The data are given in Table 1 separately for men and women. Between sexes signi cant differences were found for weight, length, volumes at all three sensations of lling. All sensations developed at a larger volume in men than in women. A speci c pattern of sensation was reported during bladder lling in all. First sensation of bladder lling, rst desire to void and strong desire to void followed each other. First sensation of bladder lling was Table 1 Urodynamic data for both sexes; volumes ml), pressure cm H 2 O) Sex Men 18) Women 32) Age Weight a Length a First sensation of lling Volume a Detrusor pressure First desire to void Volume a Detrusor pressure Strong desire to void Volume a Detrusor pressure a Significantly different between sexes. reported when the volunteers rst became aware of the bladder lling. The sensation was described as vague, as from uid in ow, it waxed and waned, and was localized in the lower pelvis. It was not recognized as a sensation normally noticed during daily life. This sensation could easily be ignored for up to a few minutes. First desire to void was recognized as a familiar, constant sensation that normally would lead a person to pass urine at the next convenient moment, but voiding could be delayed. The sensation was reported in the lower abdomen and became gradually stronger during further lling. Strong desire to void was a persistent desire to void without the fear of leakage. It was described as a constant almost uncomfortable sensation in the perineal region or urethra. It felt as a strong tension. The bladder was considered to be full, voiding as no longer to be postponed and the volunteers asked to stop the lling. Between consecutive sensations bladder volumes became statistically higher w 2, p < 0:001). The correlation between the volumes at which the consecutive sensations of lling were reported was signi cantly high, between volumes at rst sensation of bladder lling and rst desire to void r ˆ 0:832), between rst desire to void and strong desire to void r ˆ 0:816) and between rst sensation of lling and strong desire to void r ˆ 0:680). Also between detrusor pressures at each sensation a strong p < 0:001) correlation was found at rst sensation of lling and rst desire to void r ˆ 0:896), rst desire to void and strong desire to void r ˆ 0:953) and rst sensation of lling and strong desire to void r ˆ 0:785). No signi cant correlation was found between pressures and volumes at each sensation. First sensation of bladder lling was reported at 41 15, 5% of volume at strong desire to void and rst desire to void at 62 13, 9% of the volume at strong desire to void. There was no signi cant difference in these ratios between the sexes. Data on volume are shown for both studies in Fig. 1. There is no signi cant difference in ratios between both studies. Residual urine was present in only six volunteers, ve men 27:6 15:7 ml) and one woman 40 ml). During lling bladder overactivity was measured in seven one man and six women). Those with bladder overactivity reported no sensations of lling during the detrusor pressure rise, except one girl who reported a rst desire to void when an involuntary intravesical pressure rise occurred. No urinary infection was found on the sample taken during the test. No urinary infection developed during follow-up. Only minor discomfort was felt by a small majority n ˆ 34) for some days especially during

36 J.J. Wyndaele, S. De Wachter / European Urology 42 2002) 34±38 Fig. 1. Box plot presentation of volumes at reported lling sensations in study 1995 and 2000, showing median and interquartile range.

3 36 J.J. Wyndaele, S. De Wachter / European Urology ) 34±38 Fig. 1. Box plot presentation of volumes at reported lling sensations in study 1995 and 2000, showing median and interquartile range. FSF: rst sensation of bladder lling; FDV: rst desire to void; SDV:strong desire to void. voiding.when both study populations were compared signi cant differences between the groups were found for age p < 0:005) in both sexes, in men only for volume at strong desire to void p ˆ 0:007) and pressure at the same sensation p ˆ 0:044). 4. Discussion The invasiveness of cystometry might explain why the reports of urodynamic data in healthy volunteers are few. Moreover, there is little knowledge how reliable examinations in healthy volunteers are to determine normality in function. Results from urodynamic techniques depend on several technical aspects and groups of normal volunteers might be quit disparate. If however ndings prove to be consistent in several comparable groups of volunteers the evidence of the nding will become stronger. In the prospective study presented here we studied the results of a standardized cystometry in a fairly large group of healthy volunteers and compared the results with those of a group from the same European region examined 5 years earlier and by a different investigator with the same methodology [3]. The sensory data from the bladder lling prove very similar. Sensation elicited by cystometrical bladder lling has been described in several series of normal volunteers by us and by other authors [3±6]. In our group of 50 volunteers newly presented here, we could con rm that a normal pattern of sensations of bladder lling during cystometry consists of three distinct sensations. A rst sensation of bladder lling is the feeling when the person during cystometry becomes aware of the bladder lling. The sensation is not very constant and can easily be ignored for several minutes. It is probably dependent on cortical uctuation in the appreciation and interpretation [4]. This sensation has been described in patients with the hypogastric nerves being the only bladder innervation [7]. A rst desire to void is recognized as a familiar, constant sensation that normally persuades a person to seek a place to void and especially if he is home or in an environment familiar to him. The sensation does not disappear during further lling but becomes gradually stronger. A strong desire to void is recognized by all as the sensation that brings them to actively search for a toilet. The sensation is strong, constant and in different grades uncomfortable but in no way it resembles urgency. The volumes at which these three sensations occur are strongly related in each individual. Though, these volumes vary widely between individuals, they seem to occur at a fairly

4 J.J. Wyndaele, S. De Wachter / European Urology ) 34±38 37 constant ratio of total bladder lling, which is in agreement with results in animal studies [8]. Heslington and Hilton studied 22 asymptomatic female volunteers with cystometry at 100 ml/min and asked their volunteers to inform of their rst desire to void and when they felt full. They give voided volumes postcystometry of 420 ml 175±810 ml) showing again the great variation of cystometric bladder capacity in a normal population [9]. The assessment of bladder sensation felt by a person is subjective and no objective way to measure this sensation is available. Every person will always interpret and report a sensation in his own special way. This reporting is more reliable than often thought as was demonstrated before [10]. The results of ``subjective'' sensation studies during cystometry are reproducible both in short and long term. We expressly kept all information of what they might feel from the subjects and just asked them to report all sensations which bladder lling elicited. At each sensation they were asked to describe what they felt, where and if they could recognize the sensation from feelings they had during normal life. We had not an independent recording system available at that time. Such a system has the advantage to permit subjective grading of the strength of the sensations and independent marking on the cystometric curve of the time the sensation appear. But we recognize also some limitations in using such a device as it does not permit a full description of the sensations and thus can only be used if one accepts that normal sensation can be judged by three de ned points noted during lling cystometry as demonstrated again in this study and as accepted by ICS. Detrusor overactivity on conventional cystometry has been given as less frequent than if ambulatory measurements are done [11]. Turner-Warwick [12] found 10% in asymptomatic volunteers, while other authors give gures around 18% [4,5,8,15]. In our population the prevalence was 14% 5% in men, 19% in women). In the study group from 1995 no women showed overactivity and 14% of the men. It is interesting that most volunteers actually did not feel the overactive bladder contraction. If bladder overactivity with or without the simultaneous occurrence of urgency has another clinical signi cance needs to be further evaluated. The sensations of bladder lling were present and fully distinguishable from perceptions during the overactivity. Findings of conventional cystometry are limited by the constraints of rapid rates of lling. The lling rate in our study populations was 50 ml/min and 30 ml/min, respectively. This gave no change in volumes at which sensations were reported except for volume at strong desire to void in men only. Several authors have compared aspects of lling sensation in patients when different rates of lling were used:they found that between 10 and 120 ml/min the volume at strong desire to void was unchanged [13±15]. SoÈrensen et al. [13] found no difference in rst sensation of lling between 60 and 120 ml/min lling rate. Robertson [16] examined 17 healthy volunteers 11 male, 6 female; age range 22±72 years) and found higher lling volumes in both sexes if lling at 100 ml/min was used compared to lling at 50 ml/min. All these volumes are within the same range as found in our studies. That infection can in uence bladder sensation is known. In a former study in non neurologic patients we compared sensation during cystometry in 324 patients with normal urine and 31 patients with positive culture of urine but no symptoms of cystitis [17]. In the infected group rst desire to void and strong desire to void were reported at a signi cant lower volume. This underlines the importance of urine analysis in a patient examined for the sensation of bladder lling. In our volunteer groups none had infection. It becomes more and more obvious that perception of bladder lling has a normal pattern during cystometry. Impaired sensation gets a clearer clinical value. It has been published before that signi cantly more patients with neuropathy had sensation impairement [18]. The same study showed that when sensation is absent or lling is hardly felt by patients without known neuropathy further investigation could reveal pathological afferent innervation in 35%. Filling sensation has been shown to be different in bladder overactivity [19] and impairment of sensation has even been suggested as cause of an overactive detrusor behavior [20]. The latest report of the ICS Standardization of Terminology committee has de ned normal lling sensation and different types of pathological sensation which will be published this year. References [1] Wyndaele JJ. Normality in urodynamics studied in healthy adults. J Urol 1999;161:899±902. [2] Abrams P, Blaivas JG, Stanton SL, Andersen JT. The standardization of terminology of lower urinary tract function recommended by the International Continence Society. Int Urogynec J 1990;1:45±58. [3] Wyndaele JJ. The normal pattern of perception of bladder lling during cystometry studied in 38 young healthy volunteers. J Urol 1998;160:479±81. [4] Denny-Brown D, Robertson EG. On the physiology of micturition. Brain 1933;56:149±90.

5 38 J.J. Wyndaele, S. De Wachter / European Urology ) 34±38 [5] van Waalwijk van Doorn ESC, Remmers A, Janknegt RA. Conventional and extramural ambulatory urodynamics testing of the lower urinary tract in female volunteers. J Urol 1992;147:1319±26. [6] Robertson AS, Grif ths CJ, Ramsden PD, Neal DE. Bladder function in healthy volunteers:ambulatory monitoring and conventional urodynamic studies. Br J Urol 1994;73:242±9. [7] Gunterberg B, NorleÂn L, Stener B, Sundin T. Neurogenic evaluation after resection of the sacrum. Invest Urol 1975;13:183±8. [8] Morrison JFB, Sensations arising from the lower urinary tract. In: Torrens M, Morrison JFB, editors. The Physiology of the Lower Urinary Tract. Berlin:Springer, p. 89±131 [Chapter 4]. [9] Heslington K, Hilton P. Ambulatory monitoring and conventional cystometry in asymptomatic female volunteers. Br J Obstet Gynec 1996;103:434±41. [10] Wyndaele JJ. Are sensations perceived during bladder lling reproducible during cystometry? Urol Int 1992;48:299±301. [11] Thuroff JW, Jonas U, Frohnberg D, Petri E, Hohenfellner R. Telemetric urodynamics in normal males. Urol Int 1980;35:427±34. [12] Turner-Warwick RT. Some clinical aspects of detrusor dysfunction. J Urol 1975;113:539±44. [13] SoÈrensen SS, Nilsen JB, NoÃrgaard JP, Knudsen LM, Djurhuus JC. Changes in bladder volumes with repetition of water cystometry. Urol Res 1984;12:205±8. [14] Iacovou JW, Bates CP, Slow and medium ll cystometry in chronic retention. Abstract ICS Oslo, Abstract Book 1988, p. 112±3. [15] Ouslander J, Leach G, Abelson S, Staskin D, Blaustein J, Raz S. Simple versus multichannel cystometry in the evaluation of bladder function in an incontinent geriatric population. J Urol 1988;140: 1482±6. [16] Robertson A.S., Behaviour of the human bladder during natural lling:the Newcastle experience of ambulatory monitoring and conventional arti cial lling cystometry, Scand J Urol Nephrol 1999;201 Suppl):19±24. [17] Wyndaele JJ. A clinical study on subjective sensations during bladder lling. Int Urogynec J 1991;2:215±8. [18] Wyndaele JJ. Is impaired perception of bladder lling during cystometry a sign of neuropathy? Br J Urol 1993;71:270±3. [19] Wyndaele JJ. Is the sensory function of the lower urinary tract different in patients with detrusor muscle instability. ProgreÁs en Urologie 1992;2:220±5. [20] Chal n SA, Bradley WE. The etiology of detrusor hyperre exia in patients with intravesical obstruction. J Urol 1982;127:938±42. Editorial Comment F. Haab, Paris, France Besides clinical evaluation, urodynamics is considered as one of the most objective tests to evaluate adequately patients suffering from an overactive bladder. However, according to the published literature at least 30% of patients with overactive bladder without neurogenic disorders have no inhibited detrusor contractions during cystometry but still experience urgency during lling. Moreover, the clinical characterization and quanti cation of urgency is still controversial and no validated tool has been published yet. This work by Wyndaele et al. brings an interesting piece of information regarding the sensory of the bladder. This data obtained in a group of normal volunteers will be very useful both for clinical practice and to design clinical trials on new molecules acting potentially on the afferent pathway.

Urodynamic Results of Sacral Neuromodulation Correlate with Subjective Improvement in Patients with an Overactive Bladder

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