A new grading system for evaluation of uroflowmetry-EMG results (Gülhane Grading System)

Abstract

Aim: It is recommended that dysfunctional voiding diagnosis should made by the repeated uroflowmetry simultaneously pelvic floor electromyography (UF-EMG) + post void residual measurements. However, there is no evaluation system for UF-EMG parameters regarding the clinical diagnosis, follow up and treatment of these patients. In our study, we aimed to create a new grading system for the diagnosis of dysfunctional voiding by using UF-EMG parameters. Materia and Method: We have retrospectively obtained UF-EMG and lower urinary tract symptom score results that performed to the children whom applied to our clinic with the symptoms of dysfunctional voiding between 2010 and 2015. A total of 856 reports were included into this retrospective cohort analysis. The proper 610 UF-EMG tests were graded according to our grading system. The UF-EMG grading system is divided into 4 grades: Grade 0: No EMG activity and normal uroflowmetry, Gradenon-EMG: Disturbed flow pattern with no EMG activity, Grade 1: EMG activity with no disturbed flow pattern, Grade 2: EMG activity with minimally disturbed flow pattern, Grade 3: EMG activity with moderately disturbed flow pattern, Grade 4: EMG activity with extremely disturbed flow pattern. Results: There was no statistically significant difference between the demographic data of patient and control groups (p>0.05). According to grading system, day and nighttime incontinence were statistically significant increases as the grades increases (respectively, p<0,001, p=0,023). According to grading system we created as the grades increased the UF-EMG parameters and the questions of lower urinary tract dysfunction symptom score which evaluated the voiding phase results were statistically significant (p<0.05). Conclusion: Grading system will be helpful to interpreting the results of the UF-EMG, which considered to be relatively difficult and thus, the diagnosis of the patients can be easier to evaluate and respond to the treatment by urologist.

Keywords

• Lower urinary tract dysfunction
• Dysfunctional voiding
• Uroflowmetry-EMG
• Grading system

References

1. Wenke S, Van Batavia JP, Combs AJ, Glassberg KI. Analysis of uroflow patterns in children with dysfunctional voiding. J Pediatr Urol 2014; 10: 250-4.
2. Norgaard JP, van Gool JD, Hjalmas K, Djurhuus JC, Hellstrom AL. Standardization and definitions in lower urinary tract dysfunction in children. International Children’s Continence Society. Br J Urol 1998; 81: 1-16.
3. Neveus T, von Gontard A, Hoebeke P, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children’s Continence Society. J Urol 2006; 176: 314-24.
4. Austin PF, Bauer SB, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: update report from the Standardization Committee of the International Children’s Continence Society. J Urol 2014; 191: 1863-5.
5. Chase J, Austin P, Hoebeke P, McKenna P. The management of dysfunctional voiding in children: a report from the Standardisation Committee of the International Children’s Continence Society. J Urol 2010; 183: 1296-302.
6. Austin PF, Bauer SB, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children’s Continence Society Neurourol Urodyn 2016; 35: 471-81.
7. Kajbafzadeh AM, Yazdi CA, Rouhi O, Tajik P, Mohseni P. Uroflowmetry nomogram in Iranian children aged 7 to 14 years. BMC Urol 2005; 16: 5-3.
8. Gupta DK, Sankhwar SN, Goel A. Uroflowmetry nomograms for healthy children 5 to 15 years old. J Urol 2013; 190: 1008-13.

9. Combs AJ, Grafstein N, Horowitz M, Glassberg KI. Primary bladder neck dysfunction in children and adolescents I: pelvic floor electromyography lag time--a new noninvasive method to screen for and monitor therapeutic response. J Urol 2005; 173: 207-10
10. Akbal C, Genc Y, Burgu B, Ozden E, Tekgul S. Dysfunctional voiding and incontinence scoring system: quantitative evaluation of incontinence symptoms in pediatric population. J Urol 2005; 173: 969-73.
11. Koff SA. Estimating bladder capacity in children. Urology 1983; 21: 248.
12. Samijn B, Van Laecke E, Vande Walle J, et al. Uroflw measurement combined with electromyography testing of the pelvic floor in healthy children. Neurourol Urodid 2019; 38: 231-8.
13. Kılıç A, Hacıhamdioğlu DÖ, Tural E, Karademir F. Evaluation of neuropsychological development of children diagnosed with primary monosymptomatic nocturnal enuresis: A pilot study. Turk J Urol 2020; 46: 320-5
14. Ferrara P, Franceschini G, Mercurio S, Del Vescovo E, Ianniello F, Petitti T. The adverse effects of oral desmopressin lyophilisate (MELT): personal experience on enuretic children. Turk J Urol 2018; 44: 51-5.
15. Abrams P, Cardoso L, Fall M, et al. The standardization of terminology in lower urinary tract function: report from the standardisation subcommittee of the International Continence Society. Urology 2003; 61: 37-49
16. Sinha S. Dysfunctional voiding: A review of the terminology, presentation, evaluation and management in children and adults. Indian J Urol 2011; 27: 437-47.
17. Wenske S, Combs AJ, Van Batavia JP, et al. Can staccato and interrupted/fractionated uroflow patterns alone correctly identify the underlying lower urinary tract condition? J Urol 2012; 187: 2188-93.
18. Sharifi-Rad L, Seyedian SL, Fatemi-Behbahani SM, Lotfi B, Kajbafzadeh A. Impact of transcutaneous interferential electrical stimulation for management of primary bladder neck dysfunction in children J Pediatr Urol 2020; 16: 36.
19. Corcos J, Schick E. Prevelence of overactive bladder and incontinence in Canada. Can J Urol 2004; 11: 2278-84.
20. Ergin G, Kibar Y, Ebiloğlu T, et al. The role of urinary nerve growth factor for the diagnosis and assessment of the biofeedback success in children with dysfunctional voiding. J Pediatr Urol 2016; 12: 118.