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Year : 2020  |  Volume : 23  |  Issue : 9  |  Page : 1215-1220

Anterior bladder wall thickness, post-void urine residue, and bladder emptying efficiency as indicators of bladder dysfunction in Nigerian men with benign prostatic hyperplasia

1 Department of Surgery, Enugu State University of Science and Technology Teaching Hospital, Parklane-Enugu, Enugu State, Nigeria
2 Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria

Date of Submission17-Feb-2020
Date of Acceptance03-Jun-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Dr. B U Eze
Department of Surgery, Enugu State University of Science and Technology Teaching Hospital, Parklane-Enugu, Enugu State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_67_20

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Background: Benign Prostatic Hypertrophy [BPH] is associated with voiding dysfunctions. Urodynamic study is the gold standard for diagnosis of voiding dysfunctions but is invasive. Bladder wall thickness (BWT), post-void urine residue (PVR), and bladder emptying efficiency (BEE) are noninvasive predictors of voiding dysfunction. Objective: To study the relationship among BWT, PVR, and BEE in BPH. Subjects and Methods: A hospital-based cross-sectional prospective study of new BPH patients at Nnamdi Azikiwe University Teaching Hospital, Nnewi. The participants had abdominal ultrasonography measurement of anterior BWT (at bladder volume ≥200 mls), prostate volume (PV), and PVR using Prosound SSD3500 (Aloka Co Ltd, Tokyo, Japan) with an abdominal probe frequency of 3.5 MHz. Then the BEE was calculated. The anterior BWT was divided into two groups: <5 mm and ≥5 mm. The data were analyzed using SPSS version 20. Pearson's correlation was used to assess correlation and the differences between the means of the two groups of BWT were compared by Mann–Whitney test. A P- Value <0.05 was considered significant. Results: Seventy seven men with a mean age of 66.66 ± 10.74 years were included in the study. Sixty one percent had symptoms lasting >12 months. The average anterior BWT, PBV, PVR, BEE, PV, and PSA were 4.55 ± 1.02 mm, 260.98 ± 57.44 mls, 58.36 ± 52.94 mls, 77.98 ± 17.37%, 66.31 ± 46.38 mls, and 8.04 ± 5.97 ng/ml, respectively. There was a significant positive correlation between BWT and duration of symptoms (P = 0.044) and a significant negative correlation between BWT and BEE (P = 0.005). An insignificant positive correlation was found between BWT and PVR (P = 0.255). Fifty four (70.1%) had BWT <5 mm and 29.9% had BWT ≥5 mm. The mean IPSS (P = 0.000), PV (P = 0.032) and PVR (P = 0.020) were significantly higher in the ≥5 mm group. The ≥5 mm group also had a significantly lower BEE (P = 0.002). Conclusion: Voiding dysfunction was more severe in patients with BWT of 5 mm or more. There was a positive, but insignificant, correlation between anterior BWT and PVR and a significant negative correlation between BWT and BEE.

Keywords: Bladder emptying efficiency, bladder wall thickness, BPH, post-void urine residue, voiding dysfunction

How to cite this article:
Eze B U, Mbaeri T U, Orakwe J C. Anterior bladder wall thickness, post-void urine residue, and bladder emptying efficiency as indicators of bladder dysfunction in Nigerian men with benign prostatic hyperplasia. Niger J Clin Pract 2020;23:1215-20

How to cite this URL:
Eze B U, Mbaeri T U, Orakwe J C. Anterior bladder wall thickness, post-void urine residue, and bladder emptying efficiency as indicators of bladder dysfunction in Nigerian men with benign prostatic hyperplasia. Niger J Clin Pract [serial online] 2020 [cited 2022 Dec 10];23:1215-20. Available from:

   Introduction Top

Benign prostatic hyperplasia (BPH) is a common cause of urinary problems in aging men.[1] BPH leads to constriction of the urethral lumen and gives rise to lower urinary tract symptoms (LUTS).[2] BPH causes bladder outlet obstruction (BOO) which is characterized by increased detrusor pressure, increased urethral resistance, and consequent reduced urine flow rate.[3] One of the primary characteristics of BOO due to BPH is an increase in bladder mass commonly referred to as bladder hypertrophy.[4]

In men with LUTS, without prior treatment and/or neurological disorders, ultrasound-assessed Bladder Wall Thickness (BWT) has a high predictive value for BOO and can replace pressure-flow studies for the diagnosis of BOO.[5] BWT can be measured on the anterior wall, lateral walls, trigone, or dome. The BWT measurements showed minimal differences between the sections of the bladder wall where measurements were performed.[6] Though there have been conflicting reports about the usefulness of BWT as a diagnostic tool in different ethnic groups,[7],[8] ultrasound measurements of BWT have been proposed as a useful diagnostic parameter in patients with BOO and other voiding dysfunctions.[9] BWT decreases rapidly during the first 200 millilitres of bladder filling and, thereafter, remains almost stable until maximal bladder capacity.[10],[11]

The International Continence Society (ICS) Committee on Standardization of Terminology defines post-void urine residue (PVR) as the volume of urine remaining in the bladder (immediately) following the completion of voiding.[12] The measurement of post-void urine residue plays a prominent role in evaluation of men with BOO due to BPH.[13] PVR is usually measured with transabdominal ultrasound instead of urethral catheterization because transabdominal ultrasound is reliable, inexpensive, and noninvasive in nature.[14],[15] Transabdominal ultrasonography has been reported to have high sensitivity and specificity for the estimation of PVR.[15] Catheterization carries the risk of infection and trauma to the urethra[16] and may, sometimes, be difficult to perform in patients with prostatic hypertrophy.[17] Though traditionally PVR has been used as one of the key parameters to assess bladder emptying, it has been established that no absolute value of PVR is an accurate and consistently reliable measurement of adequate bladder emptying.[18] On the other hand, it has been found that bladder emptying efficiency (BEE) is a clinically meaningful method of assessing bladder emptying function.[18],[19] BEE is a product of bladder contractility against urethral resistance and is measured according to the degree of bladder emptying.[20] BEE is defined as a percentage of volume voided compared to the pre-void bladder volume.[18],[20]

To diagnose voiding dysfunction, urodynamic studies are considered as the gold standard tests. Various investigators have attempted to evaluate various noninvasive tests to predict voiding dysfunctions; for example, international prostate symptom score (IPSS), PVR, BWT, and ultrasound estimated bladder weight.[21],[22] It has been shown that a large part of BPH symptoms may be explained by bladder dysfunction, which tends to be often not considered in discussions about BPH.[23] Early identification of bladder dysfunction by measuring BWT and PVR has been shown to have the advantage of adopting therapeutic measures sufficient to prevent progression of bladder damage.[24]

To our knowledge, no local study has been carried out to assess the correlation between anterior BWT and PVR. Voiding dysfunction is not routinely evaluated in patients with BPH at the study centre. Hence, there is a need for this study. This study was done to determine the relationship among BWT, PVR, and BEE in adult Nigerian male patients with BPH.

   Subjects and Methods Top

This prospective cross-sectional study was conducted over a period of 15 months (October, 2014–December, 2015) among new BPH patients who presented to Nnamdi Azikiwe University Teaching Hospital, Nnewi. Ethical approval was obtained from the institutional ethical committee and written informed consents were obtained from the patients. The population comprised all new patients >40 years seen in the urology clinic with symptomatic BPH. Those patients with LUTS due to nonprostatic disorders, carcinoma of the prostate, previous pelvic or urethral surgeries, bladder calculi or carcinoma, neurologic deficit (s), on 5α reductase inhibitors, α-1 blockers, or anticholinergic medications and who were unable to hold enough urine to enable ultrasound measurement of parameters were excluded.

Patient evaluation included a detailed history with IPSS. A complete physical examination was done, which included digital rectal examination and neurological examination to exclude neurological deficit (s) and neurologically related bladder dysfunction. Urinalysis plus urine microscopy and culture were done to screen for diabetes mellitus and urinary tract infection. In addition, serum PSA was obtained and prostate biopsy was done for those with PSA >4 ng/ml to exclude carcinoma of the prostate.

Each subject was interviewed using a standard proforma which contained the patient's biodata, duration of symptoms, IPSS, associated symptoms, comorbidities, and ultrasound assessment of anterior BWT and PVR. To ensure quality control, only the lead researcher interviewed the patients and this was done in an enclosure to ensure confidentiality and free flow of information. BWT and PVR were assessed using transabdominal ultrasonography. The ultrasound machine used was a Prosound model SSD 3500 with an abdominal probe frequency of 3.5 MHz (Aloka co Ltd, Tokyo, Japan). Furthermore, to ensure quality control, abdominal ultrasound assessments were done by a single consultant radiologist.

The BWT was measured on the anterior bladder wall. With the assistance of magnification, the adventitia, detrusor and mucosa were identified [Figure 1]. Two ultrasonographic measurements of the anterior bladder wall in longitudinal scan and transverse scan were obtained at a bladder filling of ≥200 mls. The average was taken as the BWT value in millimetres. The average bladder wall thickness was divided into two groups (<5 mm and ≥ 5 mm) as was done by Manieri et al.[4]
Figure 1: Measurement of anterior bladder wall thickness

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Transabdominal ultrasound imaging was used to obtain both the sagittal and transverse (maintaining the same contact point and rotating the transducer through 90°) images of the largest cross sections of bladder visualized [Figure 2] both before and after voiding. The images were measured in three orthogonal directions: from the top to bottom of the bladder (y) and at 90° to this (z) in the sagittal plane and from left to right in the transverse plane (x) as was described by Dudley et al.[25] and Amole et al.[26]. The volume of urine in the bladder was calculated with the formula-
Figure 2: Measurement of pre-void and post-void urine volumes

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Urine Volume = 0.72 × Length (x) × Width (y) × Height (z)[27]

The bladder was allowed to fill with at least 200 ml of urine by asking the patient to void and then ingest at least 2 litres of water. The abdominal ultrasonography for measurement of anterior BWT was performed as from two hours later to allow adequate filling of the bladder (≥200 mls). The PVR was calculated (as the transabdominal ultrasound post-voiding volume) as soon as the patient got back from the washroom. The bladder emptying efficiency was calculated as follows-

Data collected was analyzed with Statistical Package for Social Sciences version 20 (IBM; SPSS, Chicago, IL, USA). The results obtained were expressed using tables and figures were applicable. The data was subjected to descriptive statistics and mean differences between the two groups of BWT were compared by Mann–Whitney test. Pearson's correlation was used to assess correlation where necessary. P value < 0.05 was considered significant.

   Results Top

A total of 77 men who met the stringent inclusion criteria, and signed the consent form were recruited into the study. The age range of the subjects was 43–90 years, with a mean age of 66.66 ± 10.74 years. The majority of the participants (61.0%) had symptoms lasting more than 12 months as shown in [Figure 3].
Figure 3: Percentage of participants with duration of BPH symptoms in months

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The average anterior BWT, pre-void bladder volume, PVR, BEE, prostate volume, and PSA were 4.55 ± 1.02 millimetres, 260.98 ± 57.44 millilitres, 58.36 ± 52.94 millilitres, 77.98 ± 17.37 percent, 66.31 ± 46.38 millilitres, and 8.04 ± 5.97 nanogram/millilitre, respectively.

The Pearson coefficient for the correlation between anterior BWT and duration of symptoms was 0.196 (P = 0.044). The Pearson coefficient for correlation between anterior BWT and PVR was 0.076 with a P value of 0.255. Furthermore, the Pearson coefficient for the correlation between anterior BWT and bladder emptying efficiency was -0.293 and the P value was 0.005. The scatter plots of relationships between anterior BWT and PVR and anterior BWT and BEE are shown in [Figure 4] and [Figure 5], respectively.
Figure 4: Scatter plot of relationship between anterior bladder wall thickness (mm) and post-void urine volume (mls)

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Figure 5: Scatter plot of relationship between anterior bladder wall thickness (mm) and bladder emptying efficiency (percent)

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Out of the 77 participants, 54 (70.1%) had anterior BWT < 5 mm while 23 (29.9%) had anterior BWT of 5 mm or more. The differences between those with anterior BWT <5 mm and those with anterior BWT ≥5 mm were as shown in [Table 1].
Table 1: Differences between participants with anterior bladder wall thickness of<5 millimetres (mm) and those with anterior bladder thickness of ≥5 millimetres (mm)

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   Discussion Top

The mean age of 66.66 years found in this study supports the fact that BPH is a disease of aging men and is more common in men over 50 years.[28] The mean age of 66.66 years was similar to the mean ages of 65.4 years (Aganovic et al.[29]) and 63.5 years (Güzel et al.[30]) in other parts of the world. It is also like a mean age of 61.78 years found in Africa by Elsaied and colleagues.[31]

The greater percentage of the participants (61.0%) presented more than twelve months from the onset of symptoms of BPH. Furthermore, long duration between the onset of symptoms and presentation might account for 94.8% of the participants presenting with moderate or severe grade symptoms, as assessed by IPSS, as symptoms of BPH are progressive.

The mean anterior BWT of 4.55 mm found in this study is similar to a mean BWT of 4.48 mm found in a group of patients with BPH by Ho et al.[32] It is more than the average anterior BWT of 2.2 mm reported by Jang and colleagues in a sample of healthy adults without BOO.[33] This supports the fact that infravesical obstruction by BPH can induce bladder hypertrophy.[2],[4],[33] The mean BWT in this study is smaller than the mean of 5.19 mm found by Yilmaz and others.[34] This may be due to the fact that Yilmaz and colleagues measured BWT at a lower bladder filling (150 mls), although they used the same abdominal probe frequency of 3.5 MHz as used in this study. Also, Karakose and co-workers,[28] at similar bladder filling as in this study, found a higher BWT of 5.25 mm using a higher abdominal ultrasound probe frequency of 7.5 MHz.

The mean PVR of 58.36 mls is in consonance to a mean PVR of 50.25 mls reported by Aganovic et al.[29] This value is smaller than the mean PVR of 89.97 mls and 83.27 mls found by Güzel et al.[30] and Elsaied et al.,[31] respectively. This might be due to a higher abdominal ultrasound probe frequency of 7.5 MHz used by Güzel and co-workers. It can also be due to the high inter-individual and test-retest variability of PVR as reported by Gratzke et al.[35]

This study found a positive correlation between BWT and duration of symptoms. This correlation is statistically significant (P = 0.034). This is in consonance with the works of Güzel et al.[30] and Yilmaz et al.[34] which also reported significant positive correlation between BWT and duration of obstruction. The longer the duration of symptoms, the more the bladder wall hypertrophy as the bladder tries to overcome the infravesical obstruction.

The weak positive, but not significant (P = 0.255), correlation between BWT and PVR is similar to that of Yilmaz and co-workers[34] who also reported no significant correlation between BWT and PVR. Other workers have reported significant positive correlation between BWT and PVR.[30],[36],[37] The reason why the positive correlation between BWT and PVR found in this study is not statistically significant might be because studies that found significant positive correlation used either a 6.5 MHz rectal ultrasound probe (Park et al.[36]) or a high frequency (7.5 MHz) abdominal ultrasound probe (Cakiroglu et al.[37] and Güzel et al.[30]). The use of a higher frequency ultrasound probe might lead to better resolution and more accurate measurement of anterior BWT.[38]

Comparing the differences in parameters between the two groups of BWT, significant differences were found among the prostate volume (P = 0.032), IPSS (P = 0.000) and PVR (P = 0.02) of participants with BWT <5 mm and those with BWT ≥5 mm. Participants with BWT ≥5 mm had larger mean prostate volume, IPSS score, and PVR. Yilmaz et al.,[34] found no significant difference in IPSS, prostate volume, and PVR between a similar groups of participants. This difference might arise from the fact that the bladder in their study was filled with 150 mls of saline while the bladder was allowed to be filled passively with at least 200 mls of urine in this study. Measuring bladder wall thickness at bladder volume less than 200 mls leads to a higher value.[10]

The assessment of bladder emptying is an important component in evaluating the emptying phase function of the lower urinary tract.[18] Efficient voiding requires bladder outlet relaxation followed by a detrusor contraction that is enough to overcome the remaining resistance of the outlet. Many men develop increased outlet resistance with aging as a result of prostatic hypertrophy.[4] If more than 90% bladder emptying efficiency is not achieved, it is considered as indication of voiding dysfunction.[18],[19] The mean bladder emptying efficiency of 77.98 ± 17.37 percent (range: 36.96-98.09%) found in this study is an indication of bladder dysfunction in the studied participants with BPH. The finding that the mean bladder emptying efficiency of those with BWT <5 mm (82.14%) is significantly more (P = 0.002) than that of those with BWT ≥5 mm (68.22%) shows that those with BWT ≥5 mm have significantly higher voiding dysfunction.

   Conclusion Top

The findings of this study show a positive, but statistically insignificant, correlation between BWT and PVR. It also found a significant negative correlation between BWT and bladder emptying efficiency. Voiding dysfunction, as assessed by bladder emptying efficiency, was present in patients with BPH and the dysfunction was more in patients with BWT of 5 mm or more. The implication is that patients with BWT of 5 mm or more may not likely have their symptoms completely resolved by prostatectomy because of the associated bladder dysfunction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1]

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