|Year : 2017 | Volume
| Issue : 6 | Page : 555-560
Does urodynamics study help in evaluation and prognosis of treatment in benign prostatic hyperplasia with diabetes mellitus?
Deepak A Mane, Vikram Satav, Ashwani Kandari, Abhirudra Mulay, Vilas Sabale, Sharad Kankalia
Department of Urology, Dr DY Patil Medical College, Hospital and Research Center, Dr DY Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||02-May-2017|
|Date of Acceptance||09-Aug-2017|
|Date of Web Publication||17-Jan-2018|
Dr. Vikram Satav
Department of Urology, Dr. D.Y. Patil Medical College, Sant Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Aims: The aim is to study the clinical significance of urodynamics study (UDS) in patients of benign prostatic hyperplasia (BPH), with and without diabetes mellitus (DM) and to predict the outcome of surgical depending on UDS findings. Materials and Methods: A total of 120 BPH patients were studied and divided into two groups, BPH with DM and without DM. Initial evaluation, diagnostic tests, and urodynamic examination were done in all patients, and results were statistically analyzed. Results: There was no significant difference of age and prostate volume in both groups (P > 0.05), but there was a significant increase in symptom score in patients of BPH associated with DM (P < 0.05). Bladder outlet obstruction (BOO) was found in majority of patients in our groups (96.66%) with good detrusor function. Out of 120 patients, 6 patients (2 patient in BPH group and 4 patients in BPH with DM group) had detrusor underactivity (DU). There was a significant difference in the International Prostate Symptom Score, quality of life, peak flow rate, and postvoid residual urine, pre- to post-operatively in each group (P < 0.05). Out of the 6 patients who had DU, 4 patients (1 patient in BPH group and 3 patients in BPH with DM group) showed improvement in their flow rate and symptom score. Conclusion: DM in cases of BPH patients is not the prominent factor in deciding surgical treatment. It is the severity of BOO which determines the treatment and its outcome. UDS is an invasive and costly test and does not appear to be mandatory in clinically significant BPH even if associated with DM.
Keywords: Benign prostatic hyperplasia, bladder outlet obstruction, diabetes mellitus, lower urinary tract symptoms, urodynamics
|How to cite this article:|
Mane DA, Satav V, Kandari A, Mulay A, Sabale V, Kankalia S. Does urodynamics study help in evaluation and prognosis of treatment in benign prostatic hyperplasia with diabetes mellitus?. Med J DY Patil Univ 2017;10:555-60
|How to cite this URL:|
Mane DA, Satav V, Kandari A, Mulay A, Sabale V, Kankalia S. Does urodynamics study help in evaluation and prognosis of treatment in benign prostatic hyperplasia with diabetes mellitus?. Med J DY Patil Univ [serial online] 2017 [cited 2019 Feb 19];10:555-60. Available from: http://www.mjdrdypu.org/text.asp?2017/10/6/555/223376
| Introduction|| |
Benign prostatic hyperplasia (BPH) is defined as increased number of epithelial and stromal cells within prostatic transition and periurethral zone. It is one of the most common diseases of aging males. The BPH is age dependent which normally starts after 40 years of age. The prevalence increases to 50% by the 6th decade of life and 90% by the age of 85. However, only 25%–50% of men with BPH develop bladder outlet obstruction (BOO). BPH causes BOO through two distinct mechanisms:
- Prostate enlargement (static component)
- Increased prostatic smooth muscle tone (dynamic component).
Lower urinary tract symptoms (LUTS) are the most common urological problems of elderly males, BPH leading to BOO is one of its most common causes. The relationship between BPH and LUTS is complex because not all elderly males with LUTS will have prostate enlargement and prostate enlargement may exist in the absence of LUTS. In addition, LUTS are not specific or exclusive to BPH. There are several other conditions in aging males which can cause LUTS such as neurological, chronic progressive diseases or metabolic diseases such as diabetes mellitus (DM).,,
Both BPH and DM are highly prevalent diseases in aging males. Similar to BPH, DM causes bladder dysfunction producing bothersome LUTS. LUTS secondary to BPH or DM are difficult to distinguish and can also overlap. Moreover, DM in BPH patients not only contributes to the faster growth of prostate but also leads to the development of more severe LUTS. On the other hand, BPH is not always accompanied by symptoms  As DM causes voiding dysfunction, patients of BPH associated with DM have more severe LUTS and low flow rate. This makes elderly patients with DM more prone to be misdiagnosed as BPH and subsequently subjected to surgery with poor outcome.
Therefore, the correct diagnosing of etiology in patients with BPH having LUTS associated with DM is important for therapeutic success.
Uroflowmetry and International Prostate Symptom Score (IPSS) are good screening tests for BPH but cannot differentiate between BOO and impaired detrusor contractions, for which urodynamics study (UDS) is the best tool. UDS is the most definitive test available to diagnose BOO.
There is good scientific evidence that BPH patients with DM having LUTS deserve a comprehensive evaluation, which includes UDS before treatment is instituted. This made us to take up this study.
The objective of the study is to investigate the clinical significance of UDS in patients of BPH, with and without DM and to predict the outcome of a contemplated surgical treatment.
| Materials and Methods|| |
The Institutional Ethical Committee approval was taken before commencement of study. It is a prospective cross-sectional study undertaken in the Department of Urology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune - 411 018, from October 2013 to September 2015. During a 2-year period, we collected data of BPH patients having LUTS with or without DM in our outpatient department (OPD) of urology. Men older than 55 years who had moderate-to-severe IPSS with BPH and LUTS were included in the study. Exclusion criteria were the presence of prostate cancer, bladder stone or tumors, previous prostate surgery, urethral stricture, renal failure, or neurological diseases.
A total of 120 were patients enrolled in the study, and they were divided into two groups; BPH group (Group 1) and BPH with DM group (Group 2). In Group 1-60 patients and in Group 2-60 patients were studied. These patients underwent standard diagnostic evaluation consisting of history, IPSS and quality of life (QOL), clinical examination, digital rectal examination, serum prostate-specific antigen concentration, and transabdominal ultrasound measurement of the prostate volume (PV) and postvoid residual urine (PVR), uroflowmetry, and UDS. All the parameters were recorded for statistical analysis.
Urodynamic evaluation was performed using medical measurement systems (MMS) solar apparatus, according to the standards recommended by the International Continence Society. The vesical pressure was recorded by connecting a 6Fr urethral catheter connected to the MMS solar apparatus, and 4.5 Fr rectal catheter was used to record the abdominal pressure in the patient with sitting position. For the filling of the bladder, 0.9% saline infusion was introduced through a urethral catheter, with an infusion rate of 10 ml/min. Cystometric parameters, including volume at first desire to void (FDV), maximum cystometric capacity (MCC), and detrusor pressure at maximum flow (Pdet @ Qmax), were evaluated for statistical comparison. In the study, detrusor overactivity was defined as an urodynamic observation characterized by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked, while detrusor underactivity (DU) defined as bladder contractility index (BCI) <100. BOO was also quantified using the BOO index (BOOI), in the following formula: BOOI = Pdet @ Qmax– 2 (Q max), where Pdet @ Qmax was the detrusor pressure at the maximum flow rate and the peak flow rate (Q max). The bladder outlet was defined as obstructed when BOOI >40, equivocal (20–40), and unobstructed <20. Detrusor contractility strength was also calculated, using formulae BCI; BCI = Pdet @ Qmax + 5(Q max). BCI 100–150 was considered normal and BCI <100 considered weak.
All the patients included in the study underwent standard transurethral resection of the prostate (TURP). Postoperative data were recorded in terms of the improvement of IPSS questionnaire; QOL index, Qmax, and PVR were assessed after 6 weeks of surgery.
Since the data are quantitative, we have used paired t-test to test significance in pre- and post-operative parameters in Group 1 and Group 2. For comparison between Group 1 and Group 2, we have used unpaired t-test since the groups are independent. Software used was SPSS 17.0. P value of <0.05 was considered as statistically significant.
| Results|| |
A total of 120 patients were included in the study, which were divided into two groups; Group 1 and Group 2. [Table 1] shows comparison of initial diagnostic parameters between the two groups. The mean age of the patients in Group 1 and Group 2 was 61.23 years and 63.28 years, respectively. The mean PV was 64.25 ml in Group 1 and 67.27 ml in Group 2. The mean PVR was 83.98 ml in Group 1 patients while it was 101.28 ml in Group 2. The peak flow rate in Group 1 was 7.0 ml/s; however, it was 6.38 ml/s in Group 2. There was no significant difference of age, PV, Qmax, and PVR in between both the groups. However, we found a significant relation in terms of IPSS and QOL between the groups (P< 0.05). The mean IPSS and QOL were 24.03 and 4.80 in Group 1 and 26.75 and 5.22 in Group 2 (P = 0.000 and 0.001 respectively).
|Table 1: Comparison of initial diagnostic parameters in between benign prostatic hyperplasia (Group 1) and benign prostatic hyperplasia with diabetes mellitus (Group 2)|
Click here to view
The comparison of UDS results between the two groups was statistically insignificant and is illustrated in [Table 2]. From our group of patients, we found that the UDS findings were statistically insignificant between both the groups and maximum patients were found to be obstructed.
|Table 2: Comparison of urodynamics parameters in between benign prostatic hyperplasia (Group 1) and benign prostatic hyperplasia with diabetes mellitus (Group 2)|
Click here to view
The mean Pdet @ Qmax of the patients was 75.00 cm of H2O and 73.67 cm of H2O in Group 1 and Group 2, respectively. We found 110 patients to be obstructed with good detrusor function. The mean BOOI was above 50 and the mean BCI was above 100 in both the groups. Out of 120 patients, 6 patients (2 patient in Group 1 and 4 patients in Group 2) had delayed FDV and large MCC with DU and were labeled as equivocal obstructed by calculating BOOI.
Comparison of pre- and post-operative parameters in between both the groups is shown in [Table 3] and [Table 4]. The IPSS and QOL had decreased to 6.33 and 1.85 from a preoperative score of 24.03 and 4.80 in Group 1, respectively, whereas the score in Group 2 had decreased from 26.60 and 5.03 to 9.23 and 2.07, respectively. The improvement in Qmax, pre- to post-operatively, was from 7.0 ml/s to 18.28 ml/s in Group 1 whereas from 6.3 ml/s to 15.93 ml/s in Group 2. There was reduction of mean postoperative PVR by 23.77 ml and 37.70 ml in the patients of Group 1 and Group 2, respectively. The comparison of IPSS, QOL, Qmax, and PVR in individual group was statistically significant (P< 0.05) but was statistically insignificant (P > 0.05) when compared between the two groups [Table 3] and [Table 4].
|Table 3: Comparison of pre- and post-operative parameters in between benign prostatic hyperplasia (Group 1) and benign prostatic hyperplasia with diabetes mellitus (Group 2)|
Click here to view
|Table 4: Comparison of change in pre- to post-operative parameters in between benign prostatic hyperplasia (Group 1) and benign prostatic hyperplasia with diabetes mellitus (Group 2)|
Click here to view
In Group 1, the patients who had DU on UDS also had hemoglobin A1c (HBA1c) >9. The duration of DM and HBA1c levels of the patients also influences the detrusor activity.
Of the 6 patients who had DU, 4 patients (1 patient in Group 1 and 3 patients in Group 2) had showed improvement postoperatively and their postoperative results were statistically comparable with other 110 patients who had good detrusor function in the study as shown in [Table 5]. In the remaining 2 patients, there was not much significant improvement seen postoperatively on follow-up and UDS has been planned after 3 months.
|Table 5: Comparison of change in pre- to post-operative parameters between patients with good detrusor contraction (Group A) and underactive detrusor (Group B)|
Click here to view
| Discussion|| |
The prevalence of both BPH and DM increases with age.,, As also noted in our study, the majority of patients in both groups were in their early 7th decade of life.
In our study, the men with diabetes had significant higher IPSS and poor QOL compared to those without diabetes. The studies done by Burke et al., Bang et al., Sarma et al., and Michel et al. had also found significant association of DM in severity of LUTS in BPH patients. This shows that patients of BPH with DM had more severe symptom score and poor QOL as compared to BPH patients. Recently, large population-based studies by Burke et al. and Sarma et al. had also found that DM is not directly linked with prostatic growth and more related to dynamic component of lower urinary tract function. The reason for higher IPSS in diabetic group could be attributed to autonomic neuropathy not necessarily diabetic cystopathy., However, in our study, we did not find correlation between diabetic control and DU which may be because of small sample size.
We observed majority of men had BOO (91.66%) which was defined by BOOI, and also all these men had good detrusor contractility which was defined by BCI, through UDS. The results do not correlate with most of the recent literatures. However, similar findings were observed by Boon et al. in their study. The possible explanation for higher incidence of BOO in our study could be because majority of the patients are referred cases for LUTS reporting to urology OPD.
Diabetic cystopathy was uncommon in our study; we found that 2 patients in Group 1 and 4 patients with Group 2 had DU, delayed FDV, and large MCC. Studies done by Kaplan and Blaivas had suggested that classic diabetic cystopathy may not be predominant form of lower urinary tract dysfunction, which support our findings.
We did not identify any other study in the literature that had investigated the relationship between BPH patient with or without DM through urodynamic evaluation and its prognostic value by comparing post-TURP results in one study. As in the present study, BOO due to BPH was the primary entity, so we have compared the postoperative TURP results with the other studies who had diagnosed BOO urodynamically, before doing TURP.,
TURP remains the gold standard treatment for BPH patients with moderate-or-severe LUTS.
In our study, the IPSS decreased significantly between pre- and post-operative measurements; the difference was 19.61 in Group 1. Similarly, QOL improved in Group 1 by 2.95. In Group 2, the IPSS decreased by 17.37 and QOL improved by 2.96. In terms of Qmax, we found rise of 11.28 ml/s and 9.7 ml/s in BPH and in diabetic group, respectively. The comparison of pre- to post-operatively in terms of IPSS, QOL, and Qmax index in individual group was statistically significant (P< 0.05) but was statistically insignificant (P > 0.05) when compared between the two groups except for Qmax [Table 3] and [Table 4]. There was improvement of 14.4, 2.9, and 7.8 ml/s in IPSS, QOL index, and Qmax, respectively, in the study done by Min et al. In their study, they had divided BPH patients into different groups, according to degree of obstruction seen in urodynamics, where they found greater results in obstructed group as compared to equivocal and unobstructed group. In another study done by de Lima and Netto, improvement of 12.67 and 9.7 ml/s in IPSS and Qmax, respectively, was seen in urodynamically diagnosed obstructed patients. The results of the obstruction in the present study were comparable to both the studies mentioned above.,
There was statistically significant reduction in PVR postoperatively in individual groups which reflects the high percentage of BOO in our study. The reduction in PVR postoperatively in both the groups was nearly 60 ml, which was comparable to the study done by Min et al. In the study by Min et al., they found reduction of 61.5 ml PVR postoperatively in obstructed group which was higher than equivocal and unobstructed group.
In the present study, 6 patients (2 in Group 1 and 4 patients in Group 2) who had DU and were defined equivocal obstructed through BOOI. Out of them, 4 patients (1 patient in Group 1 and 3 patients in Group 2) showed improvement postoperatively and their results were compared with rest of the patients who had good detrusor function and were defined obstructed through BOOI. Although the degree of improvement in terms IPSS, QOL index, Qmax, and PVR was superior in 110 patients then those with DU patients, this difference was not statistically significant (P > 0.05), [Table 5]. This suggests that TURP is effective in BPH patients with equivocal obstruction. These findings were consistent with the report by Min et al. and van Venrooij et al., Although no difference was noted in PV, the mean PV was 65.6 ml. This finding showed that prostatic enlargement was important factor in treatment decision. Han et al. explained the effect of TURP in patients without BOO, by suggesting that the BPH patients with weak detrusor contractility during UDS may not be diagnosed as obstruction because of insufficient rise in detrusor pressure. They reported that TURP can treat the obstruction undiagnosed in UDS to improve LUTS. Another study by van Venrooij et al. compared the outcome of TURP in obstructed, unobstructed, or equivocal men, using pre- and post-operative UDS. They showed that there is a reduction in urethral resistance factor to about 70% in obstructed group and 40% in unobstructed group post-TURP, suggesting that the reduction in urethral resistance postoperatively can increase the flow rate in patients without BOO. This could be the possible reason for improvement in flow rate and thus QOL postoperatively in 4 patients who had DU and were equivocally obstructed in the present study.
| Conclusion|| |
- BPH patients associated with DM have more severe symptom score than BPH only
- Uroflowmetry and IPSS are good screening tests for BPH but cannot differentiate between BOO and DU 
- DM in cases of BPH patients is not the prominent factor in deciding surgical treatment. In fact, it is the severity of BOO which decides the treatment as well as its outcome. Obstructed patients have excellent surgical results, but equivocally obstructed patients also benefit from surgery
- Although UDS is an invasive and costly test, it is the only test which can differentiate between BOOI and DU. However, it does not appear mandatory in clinically significant BPH and its role in BPH with DM needs further studies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Patel ND, Parsons JK. Epidemiology and etiology of benign prostatic hyperplasia and bladder outlet obstruction. Indian J Urol 2014;30:170-6.
] [Full text]
AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. J Urol 2003;170(2 Pt 1):530-47.
Zhang K, Xu Z, Zhang J, Wang H, Zhang D, Shi B. Clinical significance of urodynamic analysis in patients with benign prostatic enlargement complicated with diabetes mellitus. Urol Int 2008;81:149-52.
Min DS, Cho HJ, Kang JY, Yoo TK, Cho JM. Effect of transurethral resection of the prostate based on the degree of obstruction seen in urodynamic study. Korean J Urol 2013;54:840-5.
Dib PT, Trigo-Rocha F, Gomes CM, Srougi M. Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms. Urol Int 2008;80:378-82.
Stamatiou K, Lardas M, Kostakos E, Koutsonasios V, Michail E. The impact of diabetes type 2 in the pathogenesis of benign prostatic hyperplasia: A review. Adv Urol 2009; 2009:818965.
Soleimani M, Hoseini SY, Aliasgari M, Dadkhah F, Lashay A, Amini E. Long-term outcome of trans urethral prostatectomy in benign prostatic hyperplasia patients with and without diabetes mellitus. J Pak Med Assoc 2010;60:109-12.
Nitti VW. Pressure flow urodynamic studies: The gold standard for diagnosing bladder outlet obstruction. Rev Urol 2005;7 Suppl 6:S14-21.
Schäfer W, Abrams P, Liao L, Mattiasson A, Pesce F, Spangberg A, et al.
Good urodynamic practices: Uroflowmetry, filling cystometry, and pressure-flow studies. Neurourol Urodyn 2002;21:261-74.
Burke JP, Jacobson DJ, McGree ME, Roberts RO, Girman CJ, Lieber MM, et al.
Diabetes and benign prostatic hyperplasia progression in Olmsted County, Minnesota. Urology 2006;67:22-5.
Bang W, Lee J, Hah Y, Lee D, Ham W, Cho K. Impact of diabetes mellitus on urinary symptom in men with lower urinary tract symptoms/benign prostatic hyperplasia: A propensity score matching study. J Urol 2013;189:717-20.
Sarma AV, Burke JP, Jacobson DJ, McGree ME, St Sauver J, Girman CJ, et al.
Associations between diabetes and clinical markers of benign prostatic hyperplasia among community-dwelling Black and White men. Diabetes Care 2008;31:476-82.
Michel MC, Mehlburger L, Schumacher H, Bressel HU, Goepel M. Effect of diabetes on lower urinary tract symptoms in patients with benign prostatic hyperplasia. J Urol 2000;163:1725-9.
Boon TA, Van Venrooij GE, Eckhardt MD. Effect of diabetes mellitus on lower urinary tract symptoms and dysfunction in patients with benign prostatic hyperplasia. Curr Urol Rep 2001;2:297-301.
Kaplan SA, Blaivas JG. Diabetic cystopathy. J Diabetes Complications. 1988;2:133-9.
de Lima ML, Netto NR Jr. Urodynamic studies in the surgical treatment of benign prostatic hyperplasia. Int Braz J Urol 2003;29:418-22.
Nickel JC, Méndez-Probst CE, Whelan TF, Paterson RF, Razvi H 2010 Update: Guidelines for the management of benign prostatic hyperplasia. Can Urol Assoc J 2010;4:310-6.
van Venrooij GE, van Melick HH, Boon TA. Comparison of outcomes of transurethral prostate resection in urodynamicallyobstructed versus selected urodynamicallyunobstructed or equivocal men. Urology 2003;62:672-6.
Han DH, Jeong YS, Choo MS, Lee KS. The efficacy of transurethral resection of the prostate in the patients with weak bladder contractility index. Urology 2008;71:657-61.
National Clinical Guideline Centre (UK). The Management of Lower Urinary Tract Symptoms in Men [Internet]. London: Royal College of Physicians (UK); 2010. (NICE Clinical Guidelines, No. 97.) Appendix H, International Prostate Symptom Score (IPSS) Available from: https://www.ncbi.nlm.nih.gov/books/NBK65052/. [Last accessed on 2017 Nov 16]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]