ULTRASONOGRAPHY TO MEASURE BLADDER OUTLET OBSTRUCTION

Pressure Flow Urodynamic Studies:

The Gold Standard for Diagnosing
Bladder Outlet Obstruction
Victor W. Nitti, MD
Department of Urology, New York University School of Medicine, New York, NY

Bladder outlet obstruction (BOO) is a common cause of lower urinary tract symp-
toms (LUTS) in men and women. By definition, BOO is determined urodynamically,
assessing the pressure-flow relation during voiding. Since the 1960s much work
has been done to standardize the urodynamic definitions of obstruction in men and
more recently women. Today, urodynamic testing voiding pressure-flow analysis
remains the gold standard for the diagnosis of BOO and the etiology of LUTS. The
pressure-flow relation is much better defined in men than in women, but recent
work suggests that although the definition of obstruction may differ between men
and women, the concept of the pressure-flow relation to diagnose obstruction holds
true for both genders.
[Rev Urol. 2005;7(suppl 6):S14-S21]
© 2005 MedReviews, LLC

Key words: Lower urinary tract symptoms • Postvoid residual urine volume • Bladder outlet
obstruction • Urodynamic studies • Detrusor contractility

or years it was assumed that lower urinary tract symptoms (LUTS) in men

F were caused by obstruction by an “enlarged prostate.” The terms benign

prostatic hyperplasia (BPH) and prostatic obstruction were used interchange-
ably. Over the past 2 decades, we have developed both a better understanding of
bladder and prostate function and its relationship to symptoms and new termi-
nology.1,2 Although symptoms usually cause patients to seek treatment, several
studies have shown that there is no correlation between symptoms
and the presence of obstruction.3-6 Therefore although a diagnosis of obstruction

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 Pressure Flow Urodynamic Studies: The Gold Standard

is important, as in cases of failed these circumstances, we believe that result from several conditions
empiric treatment or before surgical the pros of urodynamic studies (gen- including neurogenic voiding dys-
intervention, further diagnostic test- eration of well-defined parameters, function, radiation cystitis, tubercu-
ing is necessary. providing a precise diagnosis lead- losis, and chronic bladder outlet
Uroflowmetry and postvoid residual ing to specific treatment with obstruction. In the case of obstruc-
urine volume (PVR) are simple tests improved outcomes, and repro- tion, compliance appears to deterio-
that can raise or lower the suspicion ducible findings) outweigh the rate as a result of high intravesical
of bladder outlet obstruction (BOO), potential cons. The latter include pressure generated by bladder
but neither can make a definitive invasiveness, time, consumption, muscular activity opposed by inap-
diagnosis. Urinary flow rate is one expense, patient discomfort and propriately high outlet resistance.14
of the simplest urodynamic tests anxiety, and the fact that symptoms Prolonged high-storage pressures
available, serving as a general indica- are not always reproduced. We are known to be detrimental to
tor of normal or abnormal voiding. recently showed the excellent tolera- renal function.15
Most men with BOO have diminished bility of urodynamic studies in men Renal deterioration associated with
flow rates,7 and 90% of men with and women of all ages, with chronic BOO is usually connected to
a maximum flow rate (Qmax) of less 95% of the patients saying they impaired compliance and high-
than 10 mL/sec are obstructed.8 would repeat urodynamic studies if storage pressures, and the finding of
Conversely, 25% to 30% of men with medically necessary. significantly impaired compliance
decreased flow are not obstructed.8 with BOO is an absolute indication
Decreased uroflow can result from Urodynamic Studies for intervention. Thus the CMG, as
impaired detrusor contractility or Urodynamic studies are the most well as the voiding pressure flow
obstruction. Without the synchronous definitive tests available to determine study, is important in the evaluation
measurement of detrusor pressure the etiology of voiding dysfunction of the potentially obstructed patient.
(Pdet), uroflow is unable to distinguish and lower urinary tract symptoms. The simultaneous measurement of
between these 2 entities.9-11 The urodynamic study can be divid- detrusor pressure and urinary flow
Furthermore, there are no features ed into 2 parts, the filling and stor- rate during voluntary voiding is one
of the uroflow curve that allow age phase (cystometrogram) and the of the best ways currently available
a definitive distinction between voiding phase (voiding pressure flow to access 2 critical parameters of
outlet obstruction and impaired study). The voiding phase allows one bladder and outlet function: detrusor
detrusor contractility.9 Similarly, to definitively make a diagnosis of contractility (normal vs impaired) and
a normal uroflow does not exclude obstruction, as detrusor pressure and outlet resistance (obstructed vs unob-
outlet obstruction.10 Elevated PVR urinary flow rate can be measured structed). In general, pressure-flow
has been shown to be more indica- and outlet resistance calculated. How- studies will identify 3 fundamental
tive of detrusor failure than of outlet ever the filling and storage phase voiding states:
obstruction.12 One study found that measured by the cystometrogram 1) Low detrusor pressure and high
50% of unobstructed men with LUTS (CMG) can provide useful information flow rate (unobstructed)
had an “elevated” PVR, and that up in the patient in whom obstruction is 2) High detrusor pressure and low
to one fourth of severely obstructed suspected, for example, detrusor over- flow rate (obstructed)
men did not.8 Elevated PVR is only activity, or involuntary contractions, 3) Low detrusor pressure with
weakly related to BOO13 and cannot may be present (with or without low flow rate (poor detrusor
be used with certainty in the diag- obstruction) and may account for contractility).
nosis of obstruction. symptoms. Sensation and capacity Although it is important to under-
Urodynamics with pressure flow also can be determined. stand these 3 fundamental patterns,
studies remain the gold standard Another overlooked urodynamic it is equally important to realize the
for diagnosing BOO and other parameter is impaired compliance. limitations of such categorization.
voiding and storage abnormalities Normally the bladder should hold Unfortunately, pressure-flow studies
responsible for LUTS and voiding increasing volumes of urine at low do not always allow for an absolute
dysfunction. Urodynamic studies are pressures indicating a highly com- classification into one distinct category.
most useful when their results will pliant structure (compliance = Borderline cases exist as well as cases
affect treatment and therefore change in volume/change in pres- in which there is a combination of
should be used judiciously. Under sure). Impaired compliance may impaired contractility and obstruction.

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Pressure Flow Urodynamic Studies: The Gold Standard continued

Measures of Outlet Resistance BOR, for any given bladder there is detrusor pressure (Pdet) at maximum
and Obstruction a specific bladder output relation and flow (Pdet @ Qmax) rate on the Y axis,
In order to use today's common the higher the bladder pressure, the they created 3 zones representing
measures of obstruction, it is impor- lower the flow and vice versa. The obstructed, unobstructed, and equi-
tant to understand basic bladder BOR essentially measures the func- vocal micturition. The zone bound-
output and urethral resistance tion of the bladder independent of the aries were created by a combination
relations. Over the past 35 years function of the urethra. of empiric observations and theoreti-
several concepts regarding urethral Griffiths further defined a method cal considerations.13 Conceptually,
resistance, bladder contractility, and to evaluate urethral resistance inde- the Abrams-Griffiths nomogram does
obstruction have been introduced. pendent of bladder function: the not permit a diagnosis of impaired
In 1997, the International Conti- urethral resistance relation (URR).18 detrusor contractility with or without
nence Society (ICS) introduced the According to this relation, as bladder coexisting BOO.
provisional ICS nomogram, which is pressure rises, the flow rate will be The passive urethral resistance rela-
now recommended for the diagnosis zero until the intrinsic bladder pres- tion (PURR) developed by Schafer20, 21
of obstruction in older men with sure equals the intrinsic urethral in 1983 constitutes a simplified
LUTS suggestive of benign prostatic pressure. At this point flow will start model of Griffith’s URR. The PURR
obstruction (BPO).16 A brief review and the flow rate will rise rapidly curve describes the relationship
of the history of pressure-flow with further increases in the intrinsic between pressure and flow during
analysis follows in an effort bladder pressure. If pairs of simulta- the period of lowest urethral resist-
to explain the ICS nomogram and neously measured values of detrusor ance (ie, during complete relaxation),
its application. pressure and flow rate are plotted and therefore defines the lowest
Attempts to mathematically define against one another throughout urethral resistance during a single
urethral resistance date back to the the course of a micturition event, voiding event. The importance of
early 1960s.17 Early equations calcu- a curve is obtained that shows the a minimum opening pressure in
lating urethral resistance, such as resistance to flow independent describing a collapsible tube is
R = Pves/Q (where R = resistance, of detrusor function, representing considered. Outlet function is char-
Pves = vesical pressure, and Q = flow the urethral resistance relation. acterized by 2 simple parameters: the
rate), followed standard hydro- A change in one of these relations minimum opening pressure, reflect-
dynamic formulae calculating outlet during micturition would not affect ing collapsibility of the tube, and the
cross-sectional area of the flow-rate
controlling zone, reflecting extensi-
Renal deterioration associated with chronic BOO is usually connected to bility.22 Therefore, the PURR curve is
impaired compliance and high-storage pressures, and the finding a method of assessing the presence or
of significantly impaired compliance with BOO is an absolute indication absence of BOO independent of
for intervention. inherent detrusor strength.
The PURR was the first attempt
to quantify relevant features of
resistance. Unfortunately, these con- the curve representing the other the voiding cycle describing the
cepts failed to consider that the relation but would result in the interplay of detrusor capability and
urethra has an active and distensible point of intersection to move along bladder outlet resistance. Schafer
nature and is not a rigid tube. They that curve. subsequently modified the PURR
also failed to consider the importance In 1979, Abrams and Griffiths by using a straight line instead of
of bladder volume. Rigid tube defined a simple nomogram for the a parabolic curve.23 Schafer divided
hydrodynamics were abandoned in diagnosis of obstruction in males.12 this linear PURR (LinPURR) curve
favor of more dynamic ways to The researchers collected pressure- into 7 zones labeled 0 to VI corre-
analyze micturition. flow data on 117 males older than sponding to increasing grades of
In 1972, Griffiths introduced age 55 years, who were evaluated obstruction: grades 0 and 1, no
Bladder Output Relation (BOR), which for possible prostatic obstruction. obstruction; grade 2, equivocal or
depicts the interrelation between By comparing pressure-flow data mild obstruction; grades 3 to 6,
bladder pressure and uroflow at between these patients and plotting increasing severity of obstruction.
a given volume.18,19 According to the the Qmax on the X axis and the The boundary between grades 2 and

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 Pressure Flow Urodynamic Studies: The Gold Standard

3 corresponds to the boundary Furthermore, an index for bladder addition, according to Abrams, the
between equivocal and obstructed in contractility can be calculated from two can be combined to categorize
the Abrams-Griffiths nomogram. the contractility groups derived from men into 1 of 9 groups representing
The linear PURR also allows for the the Schaefer nomogram. The bladder the spectrum of contractility and
assessment of detrusor contractility contractility index (BCI) is repre- obstruction (ie, from no obstruction
independent of obstruction (strong, sented by the following formula: and good contractility to obstruction
normal, weak, and very weak). BCI = PdetQmax + 5 Qmax. Using this and weak contractility26) (Figure 3).
Finally in 1989, Griffiths and associ- formula, contractility can be divided The work of several innovators
ates developed a single urethral into strong > 150, normal 100-150, over the past 35 years has led to
resistance parameter, URA.24 Using and weak < 100.26 This is represented a simplified method of diagnosing
data from a mixed group of patients, by the bladder contractility nomo- obstruction and assessing bladder
they determined that obstruction is gram (Figure 2). contractility in men. These methods
represented by URA values greater Both the BOOI and BCI can be do require urodynamic testing, which
than 29 cm H2O. simply calculated without the use is somewhat invasive, but pressure-
In the past 10 years, work has been of computer programs or even the flow analysis remains the gold stan-
done to simplify the diagnosis of nomogram for that matter. In dard for the diagnosis of obstruction
BOO in men and to create a stan-
dardized method for diagnosis, based
on the work of different authors
described above. Lim and Abrams
PdetQmax (cm H2O)

showed that patients were identically Obstructed

classified by the Abrams-Griffiths (90)
and Schafer nomograms and there
was only a 6% discrepancy between (70)
these and the URA nomogram Equivocal
described by Griffiths.25 They 40
also described the Abrams-Griffiths
number derived from the slope of the 20 Unobstructed
dividing obstructed and equivocal 0
groups on the Abrams-Griffiths 0 Qmax (mL/s) 25
nomogram and the same line divid-
ing the obstructed (II) and slightly Figure 1. The ICS nomogram. Patients are divided into 3 classes: unobstructed, equivocal, and obstructed, based
obstructed (III) on the Schafer nomo- on the Bladder Outlet Obstruction Index (BOOI). Modified from Abrams.26 ICS, International Continence Society;
Pdet, detrusor pressure; Qmax, maximum flow rate.
gram. The Abrams-Griffiths number
was later renamed the bladder
outlet obstruction index (BOOI)
and is represented by the equation: 150
Strong
PdetQmax (cm H2O)

BOOI = Pdet @ Qmax – 2 Qmax.

Based on these findings, the provi- Normal
sional ICS nomogram was subse- 100
quently published.16 Using this
nomogram, men can be divided
into obstructed, equivocal, and
unobstructed according to their Weak
BOOI: BOOI > 40 = obstructed;
BOOI 20-40 = equivocal; and BOOI 0
< 20 = unobstructed (Figure 1). For 0 30
purposes of standardization, this Qmax (mL/s)
nomogram is now recommended for
Figure 2. Bladder contractility nomogram. Patients are divided into 3 classes: strong, normal, and weak
use in older men with LUTS contractility according to the Bladder Contractility Index (BCI). Modified from Abrams. 26 Pdet , detrusor pressure;
suggestive of BPO. Qmax, maximum flow rate.

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Pressure Flow Urodynamic Studies: The Gold Standard continued

measurement of pressure and flow,

160 these techniques seem promising and
PdetQmax (cm H2O)

when eventually perfected for wide-

7 spread use may offer an additional
100 diagnostic test for assessing men
8 with LUTS.
4
9
5 Bladder Outlet Obstruction in
1
40 6 Women
2 The definitions and nomograms that
20 3
are used to describe BOO in men do
0
0 25 30 not apply to women. Clearly, men
Qmax (mL/s) and women have unique micturitional
characteristics. What is normal void-
Figure 3. Composite nomogram permitting categorization of patients into 9 zones based on the BOOI and BCI.
Modified from Abrams.26 BOOI, Bladder Outlet Obstruction Index; BCI, Bladder Contractility Index; Pdet , detrusor
ing pressure and flow rate for men is
pressure; Qmax, maximum flow rate. not necessarily normal for women.
The nomograms in men were devised
by which all other methods must between the penis and the point of based on the clinical presentation
be compared. occlusion along the catheter.28 The and response to treatment of men
second method uses a penile com- with BPO.
Noninvasive Measurement of pression cuff that can occlude the In women there is no condition
Pressure and Flow urethra before initiation of voiding that is as common as BPH and BPO
The invasive nature of urodynamic or after voiding has commenced. and therefore developing nomo-
testing has somewhat limited its In this case the cuff is inflated to grams by similar methods is diffi-
use, leading to the development of increase pressure and the pressure cult. The causes of obstruction in
several noninvasive techniques to transducer is connected to the inflat- women vary greatly from anatomic
measure bladder pressure. These able cuff.29 Both methods have (pelvic prolapse, pelvic masses,
techniques involve the measurement been shown to reproducibly measure iatrogenic obstruction after stress
of isovolumetric bladder pressure pressure and flow and correlate incontinence) to functional (dys-
combined with a free flow rate to reasonably well with invasive pres- functional voiding, primary bladder
diagnose obstruction. This is accom- sure from studies. However there is neck obstruction) without one pre-
plished by occluding urinary flow better correlation with a minimal dominant diagnosis. Despite this,
and measuring the bladder pressure voided volume of 150 mL.30-33 there has been a great interest over
transmitted along a fluid column There are several downsides to the past decade in defining BOO
between the bladder and the occlu- noninvasive methods including in women.
sion. The pressure generated by the
bladder against a closed outlet (iso-
Downsides to noninvasive methods include leakage from condom and
volumetric pressure) theoretically
condom compliance, inhibited voiding especially with the cuff technique,
should differentiate between low flow
caused by obstruction (high pressure) and cuff release problems.
and low flow caused by impaired
contractility (low pressure). An leakage from condom and condom Early definitions of obstruction
excellent review on the state of compliance, inhibited voiding were based on flow rate alone, even
noninvasive measures of pressure especially with the cuff technique, though this concept has never been
was recently written by Blake and cuff release problems.27 In accepted in males. Farrar and
and Abrams.27 addition, there is no abdominal colleagues used only flow rates to
Two techniques have been pressure monitoring to accurately diagnose obstruction as they believed
described. In the first, an external measure abdominal straining and that low flow in the presence of
condom catheter is used to interrupt there is no assessment of the storage normal or low detrusor pressures
flow distal to the urethral meatus. phase (CMG). Although clearly there might be an indication of “relative”
A pressure transducer is located are some flaws in the noninvasive obstruction. This was defined as

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 Pressure Flow Urodynamic Studies: The Gold Standard

a maximum flow rate of < 15 mL/sec and Pdet @ Qmax were used simultane- PdetQmax > 25. They also found that
with a volume of 200 mL or more.34 ously to predict obstruction, the best each individual parameter, if abnor-
Bass and Leach have stated that combination was obtained using mal, was suggestive of obstruction,
a peak flow of > 15 mL/sec with a a Qmax of 15 mL/sec or less and a Pdet even if the other parameter was
voided volume of > 100 mL, a normal @ Qmax of more than 20 cm H2O normal. In all studies there was
uroflow curve configuration, and no (sensitivity 74.3%; specificity 91.1%). a large overlap in values for Qmax and
significant postvoid residual usually This group expanded its analysis PdetQmax for individual patients who
excludes outlet obstruction.35 in 2000, including 87 clinically were obstructed or unobstructed.
In 1999, we reported the use of
simultaneous fluoroscopic imaging
of the bladder outlet during voiding
There was a significant difference in both maximum flow (Qmax) and to help make the diagnosis of
detrusor pressure at maximum flow (Pdet @ Qmax), but the parameters for obstruction.40 We defined bladder
these obstructed females are not what we would expect to see in men. outlet obstruction in women (using
videourodynamics) as radiographic
evidence of obstruction between the
Other authors introduced voiding obstructed women and 124 controls, bladder neck and distal urethra in
pressure into the definition. Massey and modified their recommendations the presence of a sustained detrusor
and Abrams proposed that 2 or more for obstruction to include a Qmax contraction, without the application
of the following 4 parameters be < 11 mL/sec and a PdetQmax > 21 cm of strict pressure-flow criteria. We
included: flow rate < 12 mL/sec, H2O (sensitivity 91.5%; specificity have found videourodynamics to be
detrusor pressure at peak flow 73.6%).38 Most recently, the group an easy and practical way to diag-
> 50 cm/H2O, urethral resistance used a similar analysis to compare nose bladder outlet obstruction in
(Pdet @ Qmax/Qmax2) > 0.2, or significant 169 clinically obstructed women to women. Equally important, it also
residual urine in the presence of high 20 asymptomatic normal controls, localizes the site.
pressure or resistance.36 The proposed citing the fact that previous controls Using these criteria in 261 consec-
pressure and flow criteria are similar (women with stress incontinence) utive women with non-neurogenic
to those used in men. As a result might not reflect a true control and voiding dysfunction we found 29%
only 2.7% of the 5948 females in fact may have a lower than nor- to be obstructed.40 There was a signif-
who presented for urodynamic eval- mal outlet resistance.39 In this study, icant difference in both maximum
uation for a variety of complaints the authors calculated that the opti- flow (Qmax) and detrusor pressure at
were “obstructed.” mal values to use were Qmax < 12 and maximum flow (Pdet @ Qmax), but the
In 1998 Chassagne and colleagues
proposed cutoff values for voiding Table 1
pressure and flow rate.37 They Comparison of Urodynamic Parameters in Obstructed and Unobstructed
prospectively studied 2 groups of Patients Using Videourodynamic Criteria*
women. Obstructed women (n = 35)
Urodynamic Obstructed Patients Unobstructed Patients
were classified based on a diagnosis Parameter (n = 76) (n = 185) P
of clinical obstruction. They were
divided into 3 groups independent of Qmax mL/s 9.0 ± 6.2 20.1 ± 10.0 < .001
urodynamic findings: 1) after
incontinence surgery, 2) secondary to Pdet @ Qmax cm H20 42.8 ± 22.8 22.1 ± 11.3 < .001
cystocele, and 3) other etiologies.
The unobstructed or control group Postvoid residual
157 ± 183 33 ± 91 < .001
(mL)
consisted of 135 women with stress
urinary incontinence and no evi- Bladder capacity
381 ± 170 347 ± 147 .11
dence of clinical obstruction. (mL)
The authors used receiver operator Detrusor
45% 41% .62
characteristic (ROC) curve analysis to instability
determine the optimum cutoff values Qmax, maximum flow rate; Pdet @ Qmax, detrusor pressure at maximim flow rate.
for Qmax and Pdet @ Qmax. When Qmax *Defined by Nitti, et al.40

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Pressure Flow Urodynamic Studies: The Gold Standard continued

that there was a significantly higher

160 flow rate in the same woman
140 Severe Obstruction (Zone 3) without a catheter, they chose to use
a noninvasive flow rate in their
Pdet.max (cm H2O)

120 nomogram. Also, because they found

100 no statistical difference in Pdet Qmax
in obstructed versus unobstructed
80 Moderate Obstruction (Zone 2) patients, they chose Pdet.max (which
60 enables analysis in patients with
urinary retention) as the pressure
40 Mild Obstruction (Zone 1)
parameter. Using cluster analysis
20 No Obstruction (Zone 0) to classify patients with low and
moderate grade obstruction, they
0
0 10 20 30 40 50 formulated the 4-zone nomogram
shown in Figure 4.
Free Qmax (mL/s) Although pressure-flow analysis
Figure 4. The Blaivas-Groutz nomogram for female obstruction. Modified from Blaivas and Groutz.41 Pdet, detru- for BOO in women is not yet as stan-
sor pressure; Qmax, maximum flow rate.
dardized as it is in men, the concept
of relatively high pressure and rela-
parameters are not what we would of > 20 cm H2O in pressure-flow tively low flow when compared to
expect to see in men. As was demon- study, or obvious radiographic normals as a measure of obstruction
strated in the ROC analyses, there obstruction in the presence of prevails. It has been shown that there
also was significant overlap in void- a sustained detrusor contraction of is reasonable agreement among the
ing parameters among obstructed > 20 cm H2O, or urinary retention 3 different methods.42 Future studies
and unobstructed patients (Table 1). or the inability to void with will help to standardize the diagnosis
In 2000, Blaivas and Groutz a transurethral catheter in place of obstruction in women.
created a nomogram using some despite a sustained detrusor contrac-
of the principles cited in the 2 tion of > 20 cm H2O. Conclusions
previously mentioned studies.41 Citing the difficulty in performing Voiding pressure flow studies remain
They defined BOO as a free Qmax uroflowmetry in women with the gold standard for the diagnosis of
< 12 mL/sec combined with a Pdet Qmax a catheter in place, and the fact BOO. In fact, obstruction itself

Main Points
• Urodynamics with pressure flow studies remains the gold standard for diagnosing bladder outlet obstruction (BOO) and other
voiding and storage abnormalities responsible for lower urinary tract symptoms (LUTS) and voiding dysfunction. Urodynamic
studies are most useful when their results will affect treatment and therefore should be used judiciously.
• Simultaneously measuring detrusor pressure and urinary flow rate during voluntary voiding is the best way currently available to
access 2 critical parameters of bladder and outlet function: detrusor contractility (normal vs impaired) and outlet resistance
(obstructed vs unobstructed).
• Noninvasive techniques that measure bladder pressure involve the measurement of isovolumetric bladder pressure combined
with a free flow rate to diagnose obstruction. Although there are downsides to noninvasive techniques, including the lack of
abdominal pressure monitoring and assessment of the storage phase, they hold promise and may offer an additional diagnostic
test for the assessment of men with LUTS.
• Definitions and nomograms used to describe BOO in men do not apply to women, and there is great interest in defining BOO
in women. The causes of obstruction in women can vary greatly from anatomic (pelvic prolapse, pelvic masses) to functional
(dysfunctional voiding, primary bladder neck obstruction) without one predominant diagnosis.
• Although pressure-flow analysis for BOO in women is not yet as standardized as it is in men, the concept of relatively high pres-
sure and relatively low flow when compared to normals as a measure of obstruction prevails. Future studies will help standardize
the diagnosis of obstruction in women.

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 Pressure Flow Urodynamic Studies: The Gold Standard

is defined based on the pressure-flow The diagnosis of bladder outlet obstruction: bladder contractility index and bladder voiding
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sure-flow relation and the characteri- Consultation on BPH. World Health Organiza- 27. Blake C, Abrams P. Non invasive techniques for
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