Review Article: Matthias Oelke

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Neurourology and Urodynamics 29:634–639 (2010)

REVIEW ARTICLE

International Consultation on Incontinence-Research Society


(ICI-RS) Report on Non-Invasive Urodynamics: The Need of
Standardization of Ultrasound Bladder and Detrusor
Wall Thickness Measurements to Quantify
Bladder Wall Hypertrophy
Matthias Oelke1,2*
1
Department of Urology, Hannover Medical School, Hannover, Germany
2
Department of Urology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands

Introduction: Ultrasonic measurements of urinary bladders are suitable to quantify bladder wall hypertrophy due
to bladder outlet obstruction, detrusor overactivity, or neurogenic bladder dysfunction in adult men or women and
in children. Quantification of bladder wall hypertrophy seems to be useful for the assessment of diseases, prediction
of treatment outcomes, and longitudinal studies investigating disease development and progression. Measurement
techniques: Four distinct measurement techniques have been published using bladder wall thickness (BWT),
detrusor wall thickness (DWT), or ultrasound-estimated bladder weight (UEBW) assessed by suprapubic or
transvaginal positioning of ultrasound probes and different bladder filling volumes. As a result, different threshold
and reference values were established causing confusion. This ICI-RS report summarizes the agreements of
different research groups in terms of ultrasonic BWT or DWT measurements, critically discusses the four ultrasonic
measurement techniques, suggests criteria for quality control, and proposes future research activities to unify
measurement strategies. Proposed standardization and research: For quality control, all future reports should
provide information about frequency of the ultrasound probe, bladder filling volume at measurement, if BWT, DWT,
or UEBW was measured, enlargement factor of the ultrasound image, and one ultrasound image with marker
positioning. The ICI-RS intends to found a standardization committee that will initiate and judge studies on
ultrasonic bladder wall measurements to clarify the most suitable, most accurate, and least invasive measurement
technique. Neurourol. Urodynam. 29:634–639, 2010. ß 2010 Wiley-Liss, Inc.

Key words: bladder wall hypertrophy; bladder wall thickness; detrusor wall thickness; estimated bladder weight;
standardization; ultrasound

INTRODUCTION investigations of bladders in patients with benign prostatic


obstruction (BPO) demonstrated that the bladder wall thickens
Bladder wall hypertrophy has been documented in men
with increasing obstruction grade.3,5 Under standardized
with bladder outlet obstruction (BOO),1 – 7 women with
conditions and with defined threshold values it is possible to
detrusor overactivity,8 – 12 and children with urethral valves,
quickly diagnose BOO with ultrasound technique; sensitivity,
dysfunctional voiding, or neurogenic bladder dysfunction (e.g.,
specificity, and predictive values of ultrasound BWT/
detrusor-sphincter-dyssynergia, low-compliance bladders).13–17
DWT measurements are similar to those of urodynamic
Bladder wall hypertrophy is caused by thickening of the
investigation3,5 – 7 and superior to other non-invasive tests
detrusor.18 It was hypothesized that detrusor wall thickness
(DWT) or bladder wall thickness (BWT) reflects the workload of
the bladder similar to the heart, in which the cardiac wall
thickens in patients affected by arterial hypertension or Abbreviations: BOO, bladder outlet obstruction; BPH, benign prostatic hyper-
cardiac valve stenosis.19 Bladder wall hypertrophy can be plasia; BWT, bladder wall thickness; DWT, detrusor wall thickness; UEBW,
imaged with ultrasound technology in experimental animals ultrasound-estimated bladder weight.
Christopher Chapple led the review process.
with partial BOO20 and humans with neurogenic or non-
Conflict of interest: none.
neurogenic bladder dysfunction. *Correspondence to: Matthias Oelke, MD, FEBU, Vice-Chairman, Department of
Imaging of the bladder wall provides information about Urology and Urological Oncology, Hannover Medical School, Carl-Neuberg-Straße
the state of hypertrophy and grade of decompensation of 1, 30625 Hannover, Germany. E-mail: oelke.matthias@mh-hannover.de
Received 14 July 2009; Accepted 16 September 2009
the urinary bladder that can be used to assess diseases (e.g.,
Published online 15 May 2010 in Wiley InterScience
BOO or detrusor overactivity) avoiding invasive, expensive, (www.interscience.wiley.com)
and time-consuming urodynamic investigations. Ultrasonic DOI 10.1002/nau.20834

ß 2010 Wiley-Liss, Inc.


ICI-RS Report on Non-Invasive Urodynamics 635
usually performed in clinical routine (uroflowmetry, measure- AGREEMENTS BETWEEN RESEARCH GROUPS
ments of postvoid residual urine or prostate volume, and
Experts agree on the following facts during ultrasonic
symptoms assessed by the International Prostate Symptom
measurements of BWT and DWT:
Score).3,5,6 In a meta-analysis of non- and minimally invasive
tests to diagnose BOO it was concluded that ultrasound BWT/
DWT measurements are one of the promising techniques . Use of high frequency ultrasound probes: The resolution of
that have the potential to replace urodynamic investigations the ultrasound image is frequency dependent: the higher the
in the future.21 A detailed description and comparison of all ultrasound frequency the better the resolution. High
promising techniques (measurements of the bladder wall, frequency ultrasound probes (e.g., 7.5 MHz) have a resolution
intravesical prostatic protrusion, and isovolumetric bladder of less than 0.13 mm, whereas ultrasound probes with a
pressure by the condom catheter method or penile cuff test) frequency of 3.5 MHz have a resolution of approximately
has been published recently.22 0.3 mm.32 Considering DWTs between 1.1 and 1.8 mm in
Furthermore, bladder wall imaging might be helpful to filled bladders of healthy male volunteers or non-obstructed
understand disease development or predict treatment out- bladders5,32 and DWTs of 2 mm or higher in patients with
come. It was shown in patients with BOO that bladder wall obstructed bladders5,7 it is important to use frequencies high
hypertrophy is quickly reversible after BOO relief.23 – 25 Ultra- enough to capture small differences.
sonic investigations of bladders in patients after transurethral . Use of digital ultrasound machines for adequate image
resection of the prostate or open prostatectomy showed enlargement: For precise marker positioning and bladder
a significant decrease of BWT as early as 1 week after the wall measurements it is necessary to enlarge ultrasound
operation and reached the nadir at about 56% of the original images. Digital ultrasound machines for clinical use can
thickness 6 weeks later.24 Patients with persistent bladder enlarge the image 5- to 15-fold. If the image has not been
wall hypertrophy after treatment remained symptomatic adequately enlarged imprecise placement of the markers
and had a poor treatment outcome.23 Ultrasound studies in would result in great measurement differences and might
men with lower urinary tract symptoms (LUTS) due to BPH suggest bladder wall hypertrophy.
showed during a-blocker treatment a decrease of symptoms . Ultrasonic appearance of the bladder wall: The outer and inner
and postvoid residual urine as well as increase of maximum layers of the bladder wall appear hyperechogenic (white)
urinary flow rate which correlated well with decrease of and represent the adventitia and mucosa/submucosal
bladder wall hypertrophy.26,27 Studies on women with tissue, respectively. The detrusor appears hypoechogenic
detrusor overactivity showed that antimuscarinic drugs can (black) and is sandwiched between the hyperechogenic lines
also reduce BWT quickly.28,29 Children with myelomeningo- of the adventitia and mucosa (Fig. 1a).1,33 Measurement of
celes and an unfavorable urodynamic pattern have increased all three layers represents BWT and measurement of the
BWT;17 however, children with sufficient treatment and detrusor only represents DWT. Therefore, BWT values are
regular follow-up investigations have DWTs similar to healthy always greater than DWT values in the same patient and
controls.30 This information might be useful to understand the direct comparison of both values is not possible (Fig. 1b).
pathophysiology of the disease, identify treatment responders . Perpendicular imaging of the bladder wall: If the bladder
or non-responders even before treatment begin, or monitor wall has been tangentially imaged measurements might
treatment. suggest bladder wall hypertrophy. Perpendicular imaging is
Last but not least, BWT/DWT measurements could be useful achieved when the hyperechogenic adventitia and mucosa
for epidemiological studies investigating disease development appear as thin and sharp lines.32
and progression over a long period of time in large groups of . Decrease of thickness with increasing bladder filling: BWT and
people, thereby avoiding bothersome urodynamic investiga- DWT depend on bladder filling in the range of 50–250 ml. It
tions, study withdrawals, or proxy parameters during follow- was first demonstrated by Khullar et al.8 that no significant
up visits. Longitudinal studies in men investigating the differences of BWT exist in almost empty bladders and those
development and progression of BOO have not yet been filled until 50 ml. Oelke et al.32 showed in healthy adult male
performed due to the above-mentioned reasons. Ultrasonic and female volunteers that DWT decreases rapidly between
investigations of BWT/DWT seem to be ideal tool for this 50 and 250 ml of bladder filling (or until 50% of bladder
purpose. However, it has already been demonstrated that capacity) but reaches a plateau thereafter with only minor
symptomatic men with BPO and bladder wall hypertrophy and insignificant differences between 250 ml and maximum
have an approximately 13 times increased risk of developing bladder capacity (Fig. 2a,b). The difference of measurements
acute urinary retention.31 at 50% and 100% bladder capacity is in the order of image
Without doubt, research on ultrasound measurements of resolution of a 7.5 MHz ultrasound array. This hyperbolic
the bladder wall has lead to a massive increase of knowledge detrusor wall characteristic is identical in both healthy men
and further understanding of bladder pathophysiology. and women and in line with results obtained in healthy
Despite several agreements on ultrasonic investigations of children34,35 and women with overactive bladder/detrusor
the bladder wall the measurement technique has not yet been overactivity with or without urinary incontinence.12
standardized. Techniques differ in terms of positioning of the . Similar thicknesses at different parts of the bladder: All parts
ultrasound probe, bladder filling, and measuring of different of the bladder (dome, anterior, posterior, or lateral walls)
parts of the bladder wall. As a result, different reference and have the same thickness in the same patient and in the
threshold values have been established causing confusion and same state of bladder filling.1,34,36 Therefore, any part of
non-acceptance of the concept in general. Correction factors to the bladder can be imaged to measure BWT or DWT and
directly translate measurement values obtained by different diagnose bladder wall hypertrophy.
techniques have not been described. The lack of standardiza- . Gender specificity of measurement values: It was shown in
tion inhibits further scientific development of ultrasound children and adults that females have a significantly lower
bladder wall measurements. This report aims to list the BWT and DWT than males.4,32,34 Higher BWT and DWT
agreements and disagreements of various research groups and values in males might reflect greater voiding pressures due
suggest future research and standardization. to the prostate and longer urethra. Therefore, measurement

Neurourology and Urodynamics DOI 10.1002/nau


636 Oelke

Fig. 1. a: Imaging of the anterior bladder wall with a linear 7.5 MHz Fig. 2. Relationship between detrusor wall thickness and bladder filling
ultrasound array, enlargement factor of the image 9.8-fold. The outer and volume (a) or bladder capacity (b) in healthy adult males.32 The measure-
inner hyperechogenic (white) lines represent the adventitia and mucosa/ ments of one volunteer are connected with lines. Detrusor wall thickness
submucosal tissue, respectively. The hypoechogenic (black) bar in between decreases rapidly until 250 ml (50% bladder capacity) and reaches a plateau
the hyperechogenic lines represents the detrusor. The measurement thereafter.
markers are positioned at the outer and inner border of the detrusor and
indicate detrusor wall thickness (2.4 mm). b: Measurement of detrusor wall
thickness (DWT) and bladder wall thickness (BWT) in the same patient,
Suprapubic Measurement Approaches
enlargement factor of the ultrasound image eightfold. For DWT measure-
ment it is necessary to measure the full distance of the hypoechogenic Supporters of the suprapubic approaches are mainly
detrusor and for BWT measurement it is necessary to measure distance from urologists who aim to assess BOO in patients with BPH or
the outer border of the hyperechogenic mucosa until the outer border of the
urethral valves or dysfunctional voiding in children. Because
hyperechogenic adventitia. BWT values in the same patient and bladder
filling are always greater than DWT values; see measurement values on the
of the low tissue penetration of high frequency ultrasound
left bottom. devices only the anterior bladder wall can be imaged with
good quality and resolution. Three distinct measurement
techniques have been published which are linked to certain
study groups:
values of females cannot be directly compared to those
obtained in males. . Tubaro technique: Tubaro and co-workers3,24 from Italy filled
. Low intra- and interobserver variabilities: Experienced bladders with 150 ml in every patient by catheterization and
centers have demonstrated that repeated measurements of measured BWT at the anterior bladder wall. BWT in male
BWT or DWT have an intraobserver variability of less than patients with BOO was significantly thicker than BWT in
5% and an interobserver variability of 4–12%.3,6,37,38 patients without BOO. A threshold value of 5 mm discrimi-
nated well between obstructed or non-obstructed bladders.
. Oelke technique: Oelke et al.32 from Germany and the
DISAGREEMENTS BETWEEN RESEARCH GROUPS
Netherlands measured DWT in bladders filled with 250 ml
Different techniques have been established to determine or more, hereby using the observation that DWT reaches a
bladder wall hypertrophy; suprapubic measurement techni- plateau at this bladder filling volume (Fig. 2a,b). Therefore,
ques can be distinguished from the transvaginal technique the exact volume in bladders filled with 250 ml or more is
(Fig. 3). not important anymore. The patients are asked to fill their

Neurourology and Urodynamics DOI 10.1002/nau


ICI-RS Report on Non-Invasive Urodynamics 637

Fig. 4. Ultrasound image of the anterior bladder wall in a patient with


hyperechogenic (fatty) tissue around the bladder which makes measure-
ments of bladder wall thickness but not detrusor wall thickness difficult.
Fig. 3. Different approaches for measurements of the bladder wall [adapted Enlargement factor of the ultrasound image 9.8-fold.
and modified from Ref. 10]. All parts of the bladder have the same thickness
in one person at the same bladder filling. Because high frequency ultrasound
probes have to be positioned close to the site the investigator wishes to bladder is excised and weighted. However, the technique has
investigate, suprapubically positioned ultrasound probes can image the the disadvantage that small measurement mistakes, either
anterior bladder wall and vaginally positioned ultrasound probes can image
at volume or BWT measurements, have a great impact on
the anterior and posterior bladder walls as well as the trigone.
UEBW because measurement values are used in the third
potency in volume formulae.5 Furthermore, it is doubtful
bladders by drinking until they feel a strong desire to void. if Caucasians have the same bladder weight compared to
This technique has the advantage that catheterization is not Asians.
necessary anymore. Arguments to measure only DWT
(instead of BWT) were (1) bladder wall hypertrophy is a
Transvaginal Measurement Approach
product of muscle cell hypertrophy due to the increased
workload of the bladder which only happens in the detrusor, Supporters of the transvaginal measurement technique are
whereas the adventitia and mucosa are not involved in gynecologists who aim to assess detrusor overactivity and
hypertrophy, (2) adventitia or mucosa could be affected by urinary incontinence. The ultrasound probe is positioned in
other diseases (e.g., inflammation or cancer) and measure- the vagina close to the bladder and enables the investigator
ment of these layers could cause a false positive increase to measure the trigone, anterior bladder wall, and dome
of BWT, (3) the hyperechogenic adventitia is sometimes with good quality and resolution. The transvaginal approach
difficult to distinguish from the perivesical fatty tissue originates from Khullar et al.8,9 from England. Patients are
making the marker placement for BWT measurements asked to empty their bladders in order to measure at bladder
difficult (Fig. 4). DWT in male patients with BOO is fillings less than 50 ml. The exact bladder filling volume in
significantly thicker than in patients without BOO.5,7 A empty bladders and those filled until 50 ml is not important
threshold value of 2 mm best distinguished between because BWT is constant in this volume range; therefore,
obstructed or non-obstructed bladders.5,7,39 The technique catheterization is not necessary. After vaginal positioning of
has been lately confirmed by Kessler et al.6 from Switzerland the ultrasound probe, BWT is measured at the anterior bladder
although a threshold value of 2.5 mm seemed more wall, trigone, and dome. All three measurement values are
appropriate to distinguish obstructed from non-obstructed added and, afterwards, divided by three to achieve mean
bladders in order to achieve similar sensitivity and specific- BWT.8 A threshold value of 5 mm best discriminated between
ity. Compared to the Tubaro approach, measurement and detrusor overactivity and other bladder conditions (normal,
threshold values are smaller with the Oelke technique stress urinary incontinence, or mixed incontinence).9 The
because bladders are filled with higher volumes and only
DWT (instead of BWT) is measured.
. Kojima technique: Kojima et al.1 from Japan measure BWT
and bladder filling volume, calculate the outer and inner
diameter of the bladder wall by volume formulas, subtract
the inner from the outer volume, and multiply the result
with the specific gravity of bladder wall tissue (Fig. 5). The
measurements and calculations result in ultrasound-esti-
mated bladder weight (UEBW) which can be independently
calculated from actual bladder filling volume. Initial experi-
ments in cadaver bladders confirmed that UEBW in the same
cadaver is more or less identical in bladders filled between
100 and 300 ml.1 A threshold value of 35 g distinguished the
Fig. 5. Schematic drawing and formulas for calculation of ultrasound-
best between obstructed and non-obstructed bladders in estimated bladder weight (UEBW) [adapted and modified from Ref. 1].
Japanese patients.1,2 The technique has the advantage that IV ¼ intravesical volume (measured by ultrasound); T ¼ thickness of the
measurement results of humans can directly be compared bladder wall (measured by ultrasound); ID ¼ inner diameter (calculated);
with those obtained in experimental animals in which the OD ¼ outer diameter (calculated); TV ¼ total vesical volume (calculated).

Neurourology and Urodynamics DOI 10.1002/nau


638 Oelke
technique has been confirmed by Robinson et al.10 although FUTURE RESEARCH
a threshold value of 6 mm might be more appropriate to
It is desirable to establish one technique and one threshold
diagnose detrusor overactivity. Criticism has appeared lately
value in men or women in order to bundle resources and
because the trigone might not been the correct measurement
unify research activities in diseased patients in the future.
location, it might be volume independent, have a different
It remains to be investigated which of the described methods
thickness compared to other bladder sites at the same bladder
is most suitable to measure bladder wall hypertrophy or if a
filling, and is likely not to be involved in bladder contractions.
new method should be established that combines advantages
The Khullar technique has the disadvantage that the ultra-
of previously described techniques (‘‘best out of all’’). For
sound probe has to be inserted into the vagina which makes
standardization of the measurement technique it is necessary
the technique invasive and, obviously, unsuitable for men.
to evaluate:
In conclusion, all techniques are capable of detecting
bladder wall hypertrophy but differ in terms of bladder
filling volume at measurement and evaluation of BWT or 1. Ideal bladder filling for measurement.
DWT. Table I summarizes the results obtained by different 2. Whether BWT, DWT, or UEBW is most suitable for exact
techniques. For quality control in the future, the following quantification of bladder wall hypertrophy.
information about ultrasonic measurements of the bladder 3. Whether the suprapubic approach delivers similar measure-
wall should be provided in all reports: ment values compared to the transvaginal approach.
4. Correction factor to directly translate measurement values
. Names of the ultrasound company and machine. of one technique to another.
. Frequency of the ultrasound probe. 5. Whether the trigone has the same thickness compared to
. Bladder filling volume/state of bladder filling at measurement. other parts of the bladder wall.
. Information whether BWT, DWT, or UEBW was measured. 6. Which measurement technique has the highest patient
. Enlargement factor of the ultrasound image during measure- acceptance and the lowest bother.
ment.
. At least one ultrasound image with maximum enlargement These questions could be answered by conducting a
and positioning of the measurement markers. study in one group of volunteers or patients measuring
. Information whether patients received treatment with both BWT and DWT at different bladder fillings and by using
a-blockers or muscarinic receptor antagonists. suprapubic as well as vaginal (rectal) ultrasound devices;
repeatability, accuracy, and measurement variation should be
Measurements that are not in line with measurement evaluated for BWT, DWT, and UEBW in this group. A recently
recommendations might result in insignificant differences published article indicates that measurement variation of
between different patients groups, as demonstrated by Blatt BWTs is lower at 250 ml compared to 150 ml.43 A multicenter
et al.42 study seems to be superior to a single center approach.

TABLE I. Different Threshold Values of Ultrasonic Measurements of the Bladder Wall or Bladder Mass in Correlation With Gender, Age, Patient Group,
Ultrasound Frequency, and Bladder Filling Volume

Threshold
Measurement Ultrasound Bladder volume at (reference)
Patient groups of frequency [MHz] measurement values

Adult men
BPH  BOO3 BWT 5.0 150 ml 5 mm
Healthy controls32 DWT 7.5 Full bladder 1.2–1.6 mmy
BPH  BOO5,7 7.5 Full bladder 2 mm
BPH  BOO6 7.5 >250 ml 2.5 mm
BPH  BOO1,2 UEBW 7.5 100–300 ml 35 g
BPH-urinary retention31 7.5 100–300 ml 35 g
Low compliance due to neurogenic bladder dysfunction13 7.5 Not mentioned 40 g
Adult women
Detrusor overactivity8,9 BWT 5–9 <50 ml 5 mm
Detrusor overactivity10 5 <50 ml 6 mm
Healthy controls32 DWT 7.5 >250 ml 1.1–1.6 mmy
Detrusor overactivity or OAB-wet12 8.0 Maximum capacity 0.75 mm
Children
Healthy neonates, age 3–7 days35 BWT 7.5 >10 ml 1.4–1.6 mmy
Healthy children, age 1 day–19 years33 5.0 or 7.5 Full bladder 1.6  0.6 mmy
Myelodysplasia and upper urinary tract deterioration17 3.5 Any bladder filling 3.3 mm
Healthy children, age 0.04–13.1 years34 DWT 7.0 >50% of bladder capacity  1.5 mmy
Healthy children, age not mentioned36 7.0 Maximum capacity 1.2  0.45 mmy
Healthy children, age 7–15 years40 7.5 Full bladder 1.3–1.6 mmy
Dysfunctional voiding16 7–10 Maximum capacity 2.6  0.5 mmy
BOO16 4.4  0.3 mmy
Healthy controls, age 22 months–18 years41 UEBW 5.0 Not mentioned 19  6 gy

BPH, benign prostatic hyperplasia; BOO, bladder outlet obstruction; BWT, bladder wall thickness; DWT, detrusor wall thickness; UEBW, ultrasound-
estimated bladder weight; full bladder, subjective feeling of full bladder (  2nd sense in cystometry); maximum capacity, maximum cystometric capacity
(  3rd sense in cystometry).

Neurourology and Urodynamics DOI 10.1002/nau


ICI-RS Report on Non-Invasive Urodynamics 639
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Neurourology and Urodynamics DOI 10.1002/nau

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