RU2814750C2 - Method for integrated diagnosis of severity of urodynamic disorders in adult patients with neurogenic dysfunction of lower urinary tract - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to urology, and can be used for diagnostics of urodynamic disorders in patients with neurogenic dysfunction of lower urinary tract. Urodynamic examination is carried out with evaluation of detrusor hyperactivity by amplitude of contractions, detrusor hyperactivity according to urodynamic schedule, coordination of urinary bladder sphincter apparatus, cystometric capacity. Also, the amount of residual urine, detrusor pressure at maximum urination rate are determined. Derived values are assigned points. If total score is from 0 to 5, normal values of urodynamic function are diagnosed, from 6 to 10 — mild degree of disturbance, from 11 to 20 — average degree of disturbance, and more than 20 points — severe degree of urodynamic disturbance.

EFFECT: method enables diagnosing the degree of severity of urodynamic disorders in adult patients by assessing a combination of the most significant values.

1 cl, 3 tbl, 3 ex

Description

The method relates to medicine, namely to the diagnosis of urodynamic disorders in patients with neurogenic dysfunction of the lower urinary tract.

Neurogenic lower urinary tract dysfunction (LUTD) develops against the background of neuropathy. Its causes are varied: spinal cord injuries, including the lumbosacral region, diabetes mellitus, acute cerebral or spinal circulatory disorders, neurological diseases (multiple sclerosis, Parkinson's disease), etc. In some patients, neuropathy is congenital and can be asymptomatic for a long time. Also, a large group consists of patients with LUTD due to surgical interventions for cancer of the pelvic organs. In many of them, urodynamic disturbances are observed in the absence of clinical symptoms, which makes timely diagnosis and determination of the severity of urodynamic disorders difficult. Thus, in patients after radical hysterectomy, dysfunction of the lower urinary tract can be diagnosed both in the early postoperative period and in the long term - a year or more after treatment. In many patients, urodynamic disturbances occur in the absence of significant clinical symptoms. The management of such patients is controversial and controversial, since symptomatic assessment of urinary disorders does not allow an accurate diagnosis. Currently, the reliability of a urodynamic (UD) study is assessed only by the experience and knowledge of the doctor who conducts the neurourological examination. Such an assessment is not always objective and may lead to the choice of ineffective or incorrect treatment tactics, thus prolonging the patient’s treatment and social rehabilitation. The UD study evaluates several dozen parameters. At the same time, one patient may have several UD disorders, which is reflected by the cumulative data of the UD examination.

The importance of conducting UD studies in the postoperative period is due to the need to obtain reliable objective information about existing disorders, and in many patients it is necessary to establish the urodynamic status before treatment in order to be able to more accurately assess postoperative disorders or identify risk factors for their occurrence. According to a study devoted to the issue of UD research as a method for diagnosing and preventing disorders of the lower urinary tract, publ. P. Benedetti-Panici. et al., in which 76% of patients had UD disorders in the absence of complaints. The examination was carried out 18 months (median follow-up 13-25) after radical hysterectomy. As a result of the study, detrusor overactivity was detected in 21% of subjects, mixed urinary incontinence in 24%, and stress urinary incontinence in 21%. Thus, it has been demonstrated that the presence or absence of subjective clinical symptoms cannot reliably indicate the degree of restoration of lower urinary tract function. At the same time, UD research remains a highly informative objective method of assessment.

Based on these facts, there was a need to create an objective tool for interpreting the LOD of the study, taking into account the parameters of filling and emptying.

The literature describes the work of urodynamic scores in children with lipomeningocele and a fixed spinal cord (G. Dushi, P. Frey, P. Ramseyer, O. Vernet, B. Meyrat. Urodynamic score in children with lipomyelomeningocele: a prospective study. The Journal of urology , Published 1 August 2011. DOI:10.1016/j.juro.2011.03.157Corpus ID: 8643408; B. Meyrat, S. Tercier, N. Lutz, B. Rilliet, M. Forcada-Guex, O. Vernet. Introduction of a urodynamic score to detect pre- and postoperative neurological deficits in children with a primary tethered cord. Child's Nervous System, Published 14 October 2003. DOI:10.1007/s00381-003-0829-7Corpus ID: 37971244). The authors used a 4-parameter assessment of LOS, including bladder volume, compliance, detrusor activity, and bladder sphincter synergy. Each parameter was scored according to the importance of deviation from normal values.

However, some parameters had a range of scores from 1 to 3, some indicators ranged from 1 to 5, which can lead to unbalanced calculations. Unbalanced scoring makes this scale difficult to use. The scales described by Meyrat focus on the filling phase. Underestimation of the emptying phase may lead to an inappropriate conclusion. The authors used the results obtained on a parametric scale to determine the indications for surgery to remove spinal cord tethering and remove lipomeningocele. Moreover, the proposed scale was used in children with asymptomatic NDMP.

The technical solution is to develop a method for interpreting a comprehensive assessment of UD disorders with the creation of a “Severity Scale for Urodynamic Disorders”, taking into account the severity in adult patients with neurogenic dysfunction of the lower urinary tract (LUTD).

The technical solution is achieved by using, just as in known methods, a parametric assessment of urodynamics (UD), including bladder volume, compliance, detrusor activity and bladder sphincter synergy.

A feature of the proposed method is that the patient is assessed in points from zero to 5 on a 6-parameter scale:

- detrusor hyperactivity by contraction amplitude (cmH2O):

< 5, then 0 points,

from 5 to 14 – 1 point,

from 15 to 19 – 2 points,

from 20 to 29 – 3 points,

from 30 to 39 – 4 points,

more than 40 – 5 points;

- detrusor hyperactivity according to the urodynamic chart:

0 points - no detrusor contractions;

1 point - the presence of low-amplitude detrusor contractions throughout the filling phase;

2 points – 1-2 amplitude contractions of the detrusor, more often at the end of the filling phase;

3 points - low-amplitude detrusor contractions throughout the filling phase and 1-2 amplitude detrusor contractions at the end of the filling phase;

4 points – 3 or more amplitude contractions;

5 points – multiple, continuous amplitude contractions of the detrusor or spasticity;

- coordination of the sphincter apparatus of the bladder:

0 points - coordinated work of the sphincter apparatus;

1 point - slight impairment of relaxation such as “dysfunctional urination”;

2 points - inconsistent dyssynergy, more often at the beginning of the emptying phase;

3 points - classic dyssynergy - throughout the entire phase of emptying without or with isolated episodes of high sphincter activity;

4 points - constant high sphincter activity or lack of relaxation during the entire phase of bowel movement, isolated type distal sphincter obstruction (IDSO);

5 points - any dyssynergy in combination with dysfunction of the upper urinary tract;

- cystometric capacity, bladder volume (% of 450 ml):

> 100 – 0 points;

from 80 to 99 – 1 point;

from 60 to 79 – 2 points;

from 40 to 59 – 3 points;

from 20 to 39 – 4 points;

< 20 – 5 points;

- amount of residual urine, volume (in%):

< 10 – 0 points;

from 11 to 20 – 1 point;

from 21 to 30 – 2 points;

from 31 to 40 – 3 points;

from 41 to 49 – 4 points;

> 50 – 5 points;

- detrusor pressure at maximum urination rate (PdetQmax in cmH2O):

< 30 – 0 points;

from 31 to 40 – 1 point;

from 41 to 50 – 2 points;

from 51 to 60 – 3 points;

from 61 to 70 – 4 points;

> 70 or absence of urination or presence of cystostomy/urethral catheter – 5 points;

and if the total points are:

- from 0 to 5, then the values are normal;

- from 6 to 10 – mild degree of violation;

- from 11 to 20 - average degree of violations;

- more than 20 points – severe degree of urodynamic disorders.

The method is carried out as follows.

The basis for the creation of the “Urodynamic Disorders Severity Scale” in adults was the equilibrium parametric assessment of urodynamic disturbances (B. Meyrat, S. Tercier, N. Lutz, B. Rilliet, M. Forcada-Guex, O. Vernet. Introduction of a urodynamic score to detect pre- and postoperative neurological deficits in children with a primary tethered cord. Child's Nervous System, Published 14 October 2003. DOI:10.1007/s00381-003-0829-7Corpus ID: 37971244). The full cycle of work of the lower urinary tract was assessed - the accumulation/filling phase and the emptying phase. Each patient is assessed on a 6-parameter scale with a “urodynamic score” assigned. The range of assessment of each of the 6 parameters is from 0 to 5, where 0 corresponds to normal values, 5 – severe violations. Each parameter is also divided according to the significance of deviations from normal values.

The following indicators were assessed:

1. Detrusor hyperactivity based on the amplitude of contractions.

2. Detrusor hyperactivity according to the urodynamic schedule.

3. Coordination of the sphincter apparatus of the bladder.

4. Cystometric capacity.

5. Amount of residual urine.

6. Detrusor pressure at maximum urination rate.

Detrusor hyperactivity by maximum contraction amplitude (cmH2O):

less than 5 - 0 points,

from 5 to 14 – 1 point,

from 15 to 19 – 2 points,

from 20 to 29 – 3 points,

from 30 to 39 – 4 points,

more than 40 – 5 points.

Detrusor hyperactivity according to the urodynamic chart:

0 points - no detrusor contractions;

1 point - the presence of low-amplitude detrusor contractions throughout the filling phase;

2 points - 1-2 amplitude contractions of the detrusor, more often at the end of the filling phase;

3 points - low-amplitude detrusor contractions throughout the filling phase and 1-2 higher amplitude detrusor contractions at the end of the filling phase;

4 points - 3 or more amplitude contractions;

5 points - multiple, non-stop amplitude contractions of the detrusor or spasticity.

Coordination of the sphincter apparatus of the bladder:

0 points - coordinated work of the sphincter apparatus;

1 point - slight impairment of relaxation such as “dysfunctional urination”;

2 points - inconsistent dyssynergy, more often at the beginning of the emptying phase;

3 points - classic dyssynergy throughout the entire voiding phase without or with isolated episodes of high sphincter activity;

4 points - constant high sphincter activity or lack of relaxation during the entire emptying phase (IDSO type);

5 points - any dyssenergy in combination with dysfunction of the upper urinary tract.

Bladder volume (% of 450 ml):

more than 100 – 0 points;

from 80 to 99 – 1 point;

from 60 to 79 – 2 points;

from 40 to 59 – 3 points;

from 20 to 39 – 4 points;

less than 20 – 5 points.

Volume of residual urine (in % of the total filling volume with free UFM):

0 points - less than 10;

1 point - from 11 to 20;

2 points - from 21 to 30;

3 points - from 31 to 40;

4 points - from 41 to 49;

5 points - more than 50.

Detrusor pressure at maximum voiding rate (PdetQmax in cmH2O):

less than 30 – 0 points;

from 31 to 40 – 1 point;

from 41 to 50 – 2 points;

from 51 to 60 – 3 points;

from 61 to 70 – 4 points;

more than 70 or absence of urination or the presence of a cystostomy/urethral catheter – 5 points.

The total number of points is from 0 to 30, with each of the 6 parameters given equal importance, and if the total score is:

from 0 to 5 – the values are normal;

from 6 to 10 – mild;

from 11 to 20 - average degree of violations;

more than 20 points – severe degree of urodynamic disorders.

Improvement was assessed when values of less than 5 points were achieved during treatment. Deterioration was assessed when it reached more than 10 points.

Clinical examples

Example 1.

Patient M., born in 1973, is observed with a diagnosis of Neurogenic bladder dysfunction. Chronic urinary retention. Condition after combined treatment (Wertheim operation + radiation therapy + chemotherapy). The patient complains of a feeling of incomplete emptying of the bladder, the need to strain to initiate and maintain the act of urination.

The patient was assessed using the Urodynamic Severity Score before treatment. The total number of points was 21 (Table 1).

Table 1

Scale of severity of urodynamic disorders (“Urodynamic Score”)

Points DG amplitude
(cmH2O) < 5 5-14 15-19 20-29 30-39 >40 0 1 2 3 4 5 DG on schedule N Low-amplitude detrusor contractions throughout filling Single amplitude contractions of the detrusor (above 15 cmH2O), more often at the end Low-amplitude contractions of the detrusor throughout and amplitude at the end Several amplitude contractions
(above 15 cmH2O) Plural amplitude detrusor contractions (above 15 cmH2O) or spasticity 0 1 2 3 4 5 Coordination N Minor impairment of relaxation according to the DM type Intermittent dissenergy, often at the beginning of the voiding phase Classic dissenergy Constantly high sphincter activity or lack of relaxation during the entire bowel movement phase (IDSO type) Any dyssenergy in combination with impaired VMP function 0 1 2 3 4 5 V mp (% of 450 ml) > 100 80-99 60-79 40-59 20-39 < 20 0 1 2 3 4 5 PVR (%) < 10 11-20 21-30 31-40 41-49 > 50 0 1 2 3 4 5 PdetQmax
(cm H2O) <30 31-40 41-50 51-60 61-70 >70/from urine in the presence of urethra. catheter UD 0 1 2 3 4 5 Total: 21 points

After collecting an anamnesis, assessing complaints, clinical and UD examination, the patient was treated with injections of botulinum toxin type A into the sphincter apparatus of the bladder. A control examination was carried out 5 weeks after injections of botulinum toxin type A. Subjectively, the patient noted an improvement in clinical parameters. According to the “Urodynamic Disorders Severity Scale,” the total score after treatment was 7 points, which corresponds to a mild degree of urodynamic disturbances.

Clinical example No. 2.

Man Sh., born in 1979, diagnosis: chronic prostatitis. He has been receiving treatment for chronic prostatitis for a long time. Repeated courses of antibacterial therapy with a short-term positive effect. Complains of frequent imperative urge to urinate, a feeling of incomplete emptying of the bladder.

According to the “Urodynamic Disorders Severity Scale,” the patient’s total score before treatment was 16, which corresponds to an average degree of urodynamic disturbances (Table 2).

table 2

Scale of severity of urodynamic disorders (“Urodynamic Score”)

Points DG amplitude
(cmH2O) < 5 5-14 15-19 20-29 30-39 >40 0 1 2 3 4 5 DG on schedule N Low-amplitude detrusor contractions throughout filling Single amplitude contractions of the detrusor (above 15 cmH2O), more often at the end Low-amplitude contractions of the detrusor throughout and amplitude at the end Several amplitude contractions
(above 15 cmH2O) Plural amplitude detrusor contractions (above 15 cmH2O) or spasticity 0 1 2 3 4 5 Coordination N Minor
relaxation disorder of the DM type Intermittent dissenergy, often at the beginning of the voiding phase Classic dissenergy Constantly high sphincter activity or lack of relaxation during the entire bowel movement phase (IDSO type) Any dyssenergy in combination with impaired VMP function 0 1 2 3 4 5 V mp (% of 450 ml) > 100 80-99 60-79 40-59 20-39 < 20 0 1 2 3 4 5 PVR (%) < 10 11-20 21-30 31-40 41-49 > 50 0 1 2 3 4 5 PdetQmax
(cm H2O) <30 31-40 41-50 51-60 61-70 >70/
void of urine in the presence of urethral catheter 0 1 2 3 4 5 Total: 16 points

After collecting an anamnesis, assessing complaints, clinical and urodynamic examination, the patient was prescribed treatment - drug therapy (alpha1-blocker in combination with a beta3-agonist) for a long course. A control examination was carried out after 2 months. Subjectively, the patient noted improvement, absence of imperative urges and normalization of the urinary rhythm. According to the “Urodynamic Disorders Severity Scale,” the total score after treatment was 5 points, which corresponds to normal values.

Clinical example No. 3.

Patient Yu., born in 1956. A random examination revealed 150 ml of residual urine and bilateral pyelectasis. The patient has a history of a coccyx fracture 12 years ago. There were no complaints at the time of inspection.

When examined on the “Urodynamic Disorders Severity Scale” before treatment, the total score was 26 points (Table 3).

Table 3

Scale of severity of urodynamic disorders (“Urodynamic Score”)

Points DG amplitude
(cmH2O) < 5 5-14 15-19 20-29 30-39 >40 0 1 2 3 4 5 DG on schedule N Low-amplitude detrusor contractions throughout filling Single amplitude contractions of the detrusor (above 15 cmH2O), more often at the end Low-amplitude contractions of the detrusor throughout and amplitude at the end Several amplitude contractions
(above 15 cmH2O) Plural amplitude detrusor contractions (above 15 cmH2O) or spasticity 0 1 2 3 4 5 Coordination N Minor
relaxation disorder of the DM type Intermittent dissenergy, more often at the beginning of the emptying phase Classic dissenergy Constantly high sphincter activity or lack of relaxation during the entire bowel movement phase (IDSO type) Any dyssenergy in combination with impaired VMP function 0 1 2 3 4 5 V mp (% of 450 ml) > 100 80-99 60-79 40-59 20-39 < 20 0 1 2 3 4 5 PVR (%) < 10 11-20 21-30 31-40 41-49 > 50 0 1 2 3 4 5 PdetQmax
(cm H2O) <30 31-40 41-50 51-60 61-70 >70/from urine in the presence of a urethral catheter 0 1 2 3 4 5 Total: 26 points

The patient was prescribed treatment - drug therapy (muscle relaxant in combination with a beta3-agonist) for a long course in combination with non-drug training techniques (tibial neuromodulation + biofeedback therapy) with a positive effect. A control examination was carried out after 2 months. According to the “Urodynamic Disorders Severity Scale”, the total score after treatment was 9 points, which corresponds to a mild degree of disturbances.

The proposed method allows specialists in functional urological diagnostics to assess the severity of urodynamic disorders of patients with UDMP using the proposed scale and makes it possible to evaluate UD parameters not only by specialists, but also by doctors of any clinical departments involved in the rehabilitation of oncological and neurological patients.

Claims (48)

A method for complex diagnosis of the severity of urodynamic disorders in adult patients with neurogenic dysfunction of the lower urinary tract, including a parametric assessment of urodynamics, including bladder volume, compliance, detrusor activity and bladder sphincter synergy, characterized in that the patient is assessed in points from zero to 5 according to 6-parameter scale: - detrusor hyperactivity by contraction amplitude, _cm2O : < 5, then 0 points, from 5 to 14 – 1 point, from 15 to 19 – 2 points, from 20 to 29 – 3 points, from 30 to 39 – 4 points, more than 40 – 5 points; - detrusor hyperactivity according to the urodynamic chart: 0 points - no detrusor contractions; 1 point – presence of low-amplitude detrusor contractions throughout the filling phase; 2 points – 1-2 amplitude contractions of the detrusor, more often at the end of the filling phase; 3 points – low-amplitude detrusor contractions throughout the filling phase and 1-2 amplitude detrusor contractions at the end of the filling phase; 4 points – 3 or more amplitude contractions; 5 points – multiple, continuous amplitude contractions of the detrusor or spasticity; - coordination of the sphincter apparatus of the bladder: 0 points – coordinated work of the sphincter apparatus; 1 point – slight impairment of relaxation such as “dysfunctional urination”; 2 points – inconsistent dissenergy, more often at the beginning of the emptying phase; 3 points – classic dyssynergy - throughout the entire phase of bowel movement without or with isolated episodes of high sphincter activity; 4 points – constant high sphincter activity or lack of relaxation during the entire phase of bowel movement, such as isolated obstruction of the distal sphincter; 5 points – any dyssynergy in combination with dysfunction of the upper urinary tract; - cystometric capacity, bladder volume, % of 450 ml: > 100 – 0 points; from 80 to 99 – 1 point; from 60 to 79 – 2 points; from 40 to 59 – 3 points; from 20 to 39 – 4 points; < 20 – 5 points; - amount of residual urine, volume in%: < 10 – 0 points; from 11 to 20 – 1 point; from 21 to 30 – 2 points; from 31 to 40 – 3 points; from 41 to 49 – 4 points; > 50 – 5 points; - detrusor pressure at maximum urination rate, PdetQmax in cmH ₂ O: < 30 – 0 points; from 31 to 40 – 1 point; from 41 to 50 – 2 points; from 51 to 60 – 3 points; from 61 to 70 – 4 points; > 70 or absence of urination or presence of cystostomy/urethral catheter – 5 points; and if the total points are: - from 0 to 5, then the values are normal; - from 6 to 10 – mild degree of violation; - from 11 to 20 - average degree of violations; - more than 20 points – severe degree of urodynamic disorders.