Review Article: Matthias Oelke
Review Article: Matthias Oelke
Review Article: Matthias Oelke
REVIEW ARTICLE
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
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
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).