Urodynamic Evaluation in Men Over 50 Years with Diabetes Mellitus and Lower Urinary Tract Symptoms – A Single Center Experience

Research Article

Austin J Urol. 2017; 4(1): 1052.

Urodynamic Evaluation in Men Over 50 Years with Diabetes Mellitus and Lower Urinary Tract Symptoms – A Single Center Experience

Ragoori D1, Sekar H2, Krishnamoorthy S2*, Kumaresan N2 and Ramanan V2

1Consultant Urologist, Asian Institute of Nephrology & Urology, India

2Department of Urology, Sri Ramachandra Medical College & RI, India

*Corresponding author: Krishnamoorthy S, Department of Urology, Sri Ramachandra Medical College & RI, Chennai, India

Received: May 20, 2016; Accepted: January 24, 2017; Published: January 26, 2017


Diabetes Mellitus affects approximately 285 million people worldwide with a steady rise in incidence over the last decade. It has been projected that 438 million individuals would be affected with diabetes by the year 2030. In India it is estimated that presently 50.8 million individuals are affected by this disease, which is likely to go up to 87 million by the year 2030. The reasons for this escalation are due to various changes in lifestyle, longer life span than before (ageing) and low birth weight could lead to diabetes during adulthood. Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms (LUTS) is a significant health problem affecting 50% of men older than 50 years of age and diabetes is another very common disease happening in the same age group.

Bladder involvement in Diabetes was recognized over 100 years ago and was established as a manifestation of diabetic neuropathy nearly 65 years ago. However it still remains an entity that is unappreciated and too frequently unrecognized. The exact incidence of voiding dysfunction caused by Diabetes Mellitus has not been clearly studied and is uncertain till date.

Keywords: Diabetes mellitus; Urinary tract symptoms


Long standing diabetes can cause bladder dysfunction, involves autonomic neuropathy leading to functional sympathetic and possible sympathetic denervation of detrusor. Impaired detrusor function results in a lower maximum flow rate and an increase in post void residual urine [1,2]. Benign Prostatic Hyperplasia (BPH) can also cause lower urinary tract symptoms, including reduced maximum flow rate and increased post void residual urine [3,4]. However, the underlying pathology is different since BPH does not primarily impair detrusor function but rather enhances bladder outlet resistance via static and dynamic components. Since diabetes and BPH increase in prevalence with age, has to be expected that a major fraction of patients with BPH concomitantly suffer from diabetes and vice versa.

Most of the diabetic patients generally do not complain of bladder symptoms. However if specifically questioned, anywhere from 5-59% of diabetics report symptoms of voiding dysfunction [5].

Diabetic cystopathy - the classical involvement or pattern of voiding dysfunction is a constellation of clinical and urodynamic findings associated with long term diabetes mellitus. The term diabetic cystopathy was coined by Frimodt-Moller in 1976 [6,8,9].Though the classical symptom of diabetic cystopathy has been well described these have not always been the pattern of voiding dysfunction in diabetes.

The patients usually have a varied symptomatic presentation. This may be due to the fact that most of these patients may have concomitant lesions such as benign prostatic hyperplasia, bladder or prostate cancer and infection. These conditions may mimic the symptoms of diabetic cystopathy and as a result diabetic patients complain of a variety of lower urinary tract symptoms.

The main differential diagnosis, at least in men is generally bladder outlet obstruction. Both these conditions produce a low flow rate and a similar symptomatic pattern. Only pressure / flow urodynamic study can differentiate between these two.

In developing countries like India where resources are limited, urodynamics is not widely available and hence not much work has been done to study the pattern of voiding dysfunction in diabetics. In a large outpatient practice in the department of urology at Sri Ramachandra Medical College and Research Institute, the clinicians are often confronted with long standing diabetic males, who present with lower urinary tract symptoms.

It poses a therapeutic challenge to the urologist treating, in deciding the line of management for these patients. It would be a difficult proposition unless and until the pattern of voiding dysfunction is clearly made out for which urodynamics remains the only answer.

Hence we embarked on this study to probe into the urodynamic evaluation of Indian diabetic men of age above 50 years with lower urinary tract symptoms. The main objectives of our study are (i) to determine the prevalence of bladder outlet obstruction and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate; (ii) to assess the predictive value of non invasive tests for BOO diagnosis and (iii) to investigate the clinical significance of urodynamic studies in diabetic men.

Materials and Methods

Urodynamic study was performed in 35 male patients with diabetes and voiding symptoms and the findings were analyzed. Data was collected in a pretested proforma meeting the objectives of the study.

The inclusion criteria are: age > 50 yrs, diabetes mellitus for a minimum duration of 5 years, IPSS score : between 7 to 30, Q.max < 15 ml/sec with a voided volume of atleast 125 ml and patients with urinary retention.

The exclusion criteria are: Prior surgical intervention, carcinoma prostate, stricture urethra, neurological diseases, active infection and vesical calculus.

Hence patients who were long standing diabetics for a minimum of 5 years and lower urinary tract symptoms were selected for the study to find out the efficacy of urodynamic evaluation in deciding the treatment option for diabetic men with LUTS.

The parameters that were included in this present study were:

Ultrasound of abdomen was done to assess the status of the upper tracts, any other lesions in bladder (growth, diverticula or Calculi), prostate architecture, size and configuration (median lobe) and post void residual urine. Urine culture was done to rule out pyuria and UTI. In the presence of UTI, the patients were subjects to a course of antibiotic therapy and urine examination was repeated before performing the urodynamic evaluation. Patients were not subjected to UDE in the presence of an active infection.

Urodynamic evaluation consisted of multi-channel urodynamics measuring abdominal, vesical and detrusor pressures simultaneously. Following cystometrogram, pressure flow studies were done. Uroflometry was performed along with simultaneous recording of the vesical pressures. The machine used for this purpose was Urolab Janus IV (Life-Tech® Inc).

A 6F and 10F infant feeding tubes were introduced simultaneously into the bladder transurethrally. The bladder was then emptied completely using these tubes. The 10F tube was used for bladder filling with saline at room temperature at a medium fill rate of 30-70 ml / min. The vesical pressures were measured using the 6F feeding tube. The intra abdominal pressures were recorded using a rectal tube with a water filled balloon. Both the pressures were then simultaneously recorded by the machine. Any involuntary vesical pressure rise that was associated with urgency was defined as Detrusor instability [7].

The bladder volume at which the patient complains of discomfort or develops a bladder contraction was defined as the bladder capacity. Once the bladder capacity was reached, the filling line (10F tube) was removed and the patient instructed to void and pressure flow recording were done.

Once the recordings were obtained, depending upon Bladder Outlet Obstructive Index (BOOI) and Bladder Contractility Index (BCI) the patients were grouped as follows:

BOOI = Pdet Qmax - 2Qmax

BCI = Pdet Qmax + 5Qmax

Patients with BOOI > 40 were classified as patients with bladder outlet obstruction. Patients who had BOOI of >20 and <40 were considered to be INDETERMINATE or EQUIVOCAL. Patients who had poorly sustained or weak detrusor contraction (BCI of less than 50) were considered to have detrusor underactivity.

Once the patients were grouped into their respective categories, their data was analyzed.


The following are the observations made in this study. A total of 35 men aged 50 years and above with diabetes mellitus for a minimum duration of at least 5 years and lower urinary tract symptoms were analyzed.

Table 1 describes the age distribution of the patients in our study. The age of these patients ranged from 50 to 89 years with a mean age of 68.22 years. There were 11 patients (31.42%) who presented in 7th and 8th decades of life and 5 patients (14.28%) in the 9th decade of life.