Accuracy of total bladder volume and residual urine

measurements: Comparison between real-time ultrasonography

and catheterization
Thomas C. Mainprize, MD, and Harold P. Drutz, MD
Toronto, Ontario, Canada
The practical value of ultrasonography as a rapid means to accurately determine total bladder volumes
and residual urine volume was assessed. Transverse and sagittal bladder diameters were measured with
real-time ultrasonography in 50 women: (1) before uroflowmetry, (2) before supine postvoiding
catheterization, (3) before standing catheterization, and (4) after standing catheterization. Calculated
bladder volumes, by use of the measured diameters, for each of eight formulas from the literature were
compared with their correspondrng measured total urine volume, total residual volume, and standing
residual volume. The lower limit of ultrasonographic visualization of urine in the bladder was approximately
42 m!. No correlation existed between calculated ultrasound bladder volumes and measured urine volumes
for any of the eight formulas. Standing residual volumes were measured In 96% of cases. Ultrasonography
cannot as yet rapidly measure bladder volumes accurately. Catheterization remains the best method of
assessing postvold residuals: supine measurements, the gold standard, should be augmented by standing
measurements when more accurate volumes are required. (AM J OSSTET GVNECOL 1989;160:1013-6.)
Key words: Real-time ultrasonography catheterization, standing residual urine, calculated
bladder volume, measured urine volume
Ultrasonographic determination of bladder volumes
is simple' and noninvasive.' e Even children are less
distressed by an ultrasonographic assessment than by
catheterization.' Obesity,' , dense pubic hair,' abdom-
inal distention,' and irregular shape of the bladder'
produce poor-quality results and have led to a search
for an appropriate formula. Formulas that use sagittal
and transverse bladder diameters \ '-7 and bladder
areas
e
" 'I have been used to calculate bladder volumes.
Calculated bladder volumes have been compared to
fixed volumes of Huid infused into an empty bladder
and to measured bladder volumes obtained by cathe-
terization of the bladder. Ultrasonography has detected
small residual urine volumes in the bladder that are
missed by catheterization/ but catheterization remains
the most accurate method' of determining residual
urine volume. Catheterization is usually done in the
supine position.
Fig. 1. Sagittal view of bladder showing height ( H) and depth
(Ds) measurements.
This study was undertaken to assess the practical
value of ultrasonography as a rapid means to accurately
determine total bladder and residual urine volumes.
From the Gynecologlcal Urology and Urodyna/nlc Investigative Umt,
Mount Smal Hospital, and the Department of ObstetriCs and Gy-
necology, Umverslly of Toronto.
Presented at the F ortyjourth Annual Meeting of The Society of Ob-
stetrlcwus and Gynaecolo[!;lStl of Canada, Vancouver, Brltllh Co-
/umbw, Canada. June 21-25, 1988.
Repnnt requests: Dr. H. P Drutz, Sulfe 1221, Mount SmalHolpltal.
6()O Ave .. Toronto. Ontarzo. Canada lH5G IX5.
Material and methods
Fifty female patients with chronic, persistent lower
urinary tract symptoms were asked to participate in the
study during routine visits to the Mount Sinai Hospital's
Urodynamic Investigative Unit. An Aloka SSD-720
real-time scanner (Omnium Medical Devices of Can-
ada, Richmond Hill, Ontario) with a 3 MHz transducer
was used to measure sagittal height (H) and depth
(Ds) (Fig. I) and transverse width (W) and depth (Dt)
1013
1014 Mainprize and Drutz
A
TRANSVERSE PLANE
Fig. 2. Transverse view of bladder showing width (W) and
depth (DI) measurements.
(Fig. 2). Scans were repeated until maximum values
were obtained.
When the women experienced a strong sensation
to void, the first of four sets of ultrasonographic
measurements was made. Uroflowmetry and perianal
electromyography, with surface electrodes, were per-
formed with a DISA 2100 uroflow system (DISA
Elektronik A/S, DK-2740 Skovlunde, Denmark). The
voided volume recorded by the DISA 2100 system was
confirmed by measuring the volume with a 250 ml
graduated cylinder. A second set of ultrasonographic
diameters was measured to assess the residual bladder
volume.
With a sterile technique, an Fr. 10 Foley catheter was
inserted, and the bladder was drained into a 250 ml
graduated cylinder to measure the supine bladder re-
sidual. A sample of urine was sent for culture. When
no further urine was returned through the catheter,
the catheter bulb was inflated with 5 ml of normal saline
solution in the bladder and the catheter was clamped.
A third set of ultrasonographic diameters of the blad-
der was taken. The patient was asked to stand, the
catheter bulb was deflated, and the catheter un-
clamped. The urine was collected in the graduated cyl-
inder as the catheter was withdrawn and the standing
residual urine volume was measured. The last of four
April 1989
Am J Obstet Gynecol
Table I. Uroflowmetry results (N = 50)
Voided volume (ml)
Peak flow (mil sec)
Mean flow (ml/sec)
Voiding time (sec)
Residual (ml)
Time to peak flow (sec)
Mean SD
319 167
19.8 10.3
8.1 6.4
89.5 86.0
156 115
II 14
Range
69 -774
3.5 - 48.8
1.0 - 32.1
9 - 399
13 - 567
1 - 85
Pattern: continuous, n = 35; intermittent, n = 15.
ultrasonograms was obtained with the patient supine
to confirm that the bladder was empty.
The bladder diameters measured with ultrasonog-
raphy were used to calculate three bladder volumes
(total bladder capacity, total residual volume, and
standing residual volume). These were calculated from
each of eight formulas taken from the literature:
H x Ds X W
7
(1)
W x Ds x H x TI"
6
(2)
H X Ds x W - 3.14"
2.17
( 3)
H X Ds x W X 0.7
1l1
( 4)
H x Ds X W X 0.625' ( 5)
H x W X (Ds + Dt)"
2 (6)
H X Ds X 6.6' (7)
W x H X 12.56" ( 8)
Accuracy was calculated by the method reported by
Griffiths et al.": Volume calculated .;- Volume mea-
sured. Percent error was determined by the for-
mula: (Volume calculated - Volume measured) x
100 .;- Volume measured.
Results
The average age was 53.8 years (range 20 to 78).
Four patients had positive urine cultures: Escherichia
coli (n = 2), Proteus mirabilis (n = 1), and group B
streptococci (n = 1). Uroflowmetry results are re-
corded in Table I. Perianal electromyographic activity
was reported as normal in 27 and increased in 23 cases.
Six women had empty bladders by ultrasonography
after uroflowmetry; supine residual volumes measured
13 to 28 ml. Ten women had empty bladders on ultra-
sonography after supine catheterization, but only two
women had no standing residual volume. Forty-eight
(96%) patients had standing residual urine volumes
and 36% had residuals >30 ml.
A total of 104 sets of ultra so no graphic measurements
were recorded; 68 of these sets were associated with
measured bladder volumes> 150 ml. The average ac-
curacy and percent error for each formula are shown
Volume 160
Number 4
Bladder volume- Ultrasonography versus catheterization 1015
Table II. Accuracy and percent error for each formula with all calculated formulas (N = 104) and
measured urine volumes> ISO ml (n = 68)
Accuracy % Error
All formula> Volume> 150 ml All formulas Volume> 150 ml
(N = 10-1) (n = 68) (N = 104) (n = 68)
Formula No. (mean SD) (mean SD) (//lean SD) (mean SD)
1 0.76 0.54 0.95 0.54 49 32 41 34
2 0.40 0.28 0.50 0.28 62 24 53 23
3 0.35 0.25 0.43 0.25 67 24 58 23
4 0.54 0.38 0.68 o.:n 53 27 44 25
5 0.48 0.33 0.59 0.34 57 26 47 23
6 0.75 0.51 0.92 0.50 47 32 39 32
7 0.66 0.31 0.71 0.33 41 22 38 21
8 1.41 0.69 1.40 0.60 59 54 53 49
in Table II. The number of times each formula gave a
calculated volume closest to the measured volume was
as follows: (I) 13,* (2) 3, (3) 4, (4) 8, (5) 0, (6) 18,*
(7) 20, t and (8) 41. No bladder volume ;:,,42 ml was
missed by ultrasonography; five of 50 measured urine
volumes <42 ml were identified by ultrasonography.
Comment
As a simple, noninvasive test, ultrasonography would
appear to be perfect for assessing bladder volumes. The
many formulas in the literature attest to the difficulty
in finding one formula to fit irregular geometric blad-
der configurations.' Bladder volumes have been cal-
culated by means of measurements of bladder diameter
and surface area. No clear consensus as to which is
better has been reached; surface area has been reported
as being better than diameter' and vice versa.
7
The use of transverse or sagittal diameters or both
is the most commonly reported method and is quicker
to perf()rm than serial area measurements. In the
search for a rapid method for office use, we chose
to explore the approach with transverse and sagit-
tal diameter measurements. Of the eight formulas
taken from the literature, the greatest accuracy was
achieved by multiplying as follows: Sagittal height x
Sagittal depth x Transverse width.
7
The lowest per-
cent error was achieved with the formula: Sagittal
height x Sagittal depth x 6.6." The formula produc-
ing the largest number of calculated volumes clos-
est to the measured volumes was: Sagittal height x
Transverse width x 12.56." No one formula proved
to be better for quantitative assessment of bladder
volumes.
To provide a truly objective assessment of the ultra-
sonography technique to replace catheterization, we
*On two occasions more than one formula gave the same
result.
tOn one occasion more than one formula gave the same
result.
felt that all calculated volumes should be included. The
inclusion of cases where measurements were hindered
because of obesity or where more than the usual su-
prapubic pressure was necessary to identify the bladder
contributed to the poor results. Unfortunately, these
situations occur commonly and need to be included in
the objective assessment.
The qualitative assessment of bladder volume had a
limit of approximately 42 ml. All 99 measured volumes
;:,,42 ml were visualized by ultrasonography, but only
five of 50 (10%) volumes <42 ml were identified.
If the normal upper limit of 50 ml for residual urine
volume is used, then ultrasonography is an excellent
technique qualitatively. Our investigative unit uses 30
ml as the upper limit for residual urine volume and we
urge patients to strive for this goal. Qualitative assess-
ment of bladder volumes has not yet replaced cathe-
terization in our unit.
Even catheterization, the gold standard for assessing
residual urine volumes, has its limitations. Hakenberg
et a!." reported identifying residual urine with ultra-
sonography after catheterization. Ninety-six percent of
our patients had additional residual urine volumes with
standing measurements after supine catheterization for
residual volumes was completed. Of the 48 patients, 17
(36%) had volumes >30 ml. Studies that relied on ul-
trasonography alone' x to confirm bladder emptiness
may be misleading in their assessment of true bladder
capacity.
Catheterization remains the most accurate method
of assessing residual bladder volumes, especially if aug-
mented by standing residual urine measurements. Ul-
trasonography is poor for quantitative assessment of
bladder volumes, particularly at the low residual vol-
umes. Although ultrasonography provides good qual-
itative assessment of bladder volumes, it fails for low
bladder volumes. Ultrasonography is useful where the
risks of an accurate measurement outweigh the benefits
of a less accurate assessment, as in children. I The use
1016 Mainprize and Drutz
of a vaginal or rectal probe may provide better quali-
tative assessment, but this has yet to be proved; the
problem of quantitative assessment because of irregular
bladder configuration is unlikely to be improved with
a vaginal or rectal probe. In a future study we intend
to compare the accuracy of these various methods of
ultrasonographic measurement of bladder volumes.
REFERENCES
1. Harrison NW, Parks C, Sherwood T. Ultrasound assess-
ment of residual urine in children. Br] UroI1976;47:805-
14.
2. Rageth ]C, Langer K. Ultrasonic assessment of residual
urine volume. Urol Res 1982;10:57-60.
3. Hakenberg OW, Ryall RL, Langlois SL, Marshall YR. The
estimation of bladder volume by sonocystography] Urol
1983; 130:249-51.
4. Ravichandran G, Fellows GJ. The accuracy of a hand-held
real time ultrasound scanner for estimating bladder vol-
ume. Br] UroI1983;55:25-7.
Bound volumes available to subscribers
April 1989
Am J Obstet Gynecol
5. Poston GJ, Joseph AEA, Riddle PRo The accuracy of ul-
trasound in the measurement of changes in bladder vol-
ume. Br J Urol 1983;55;361-3.
6. McLean GK, Edell SL. Determination of bladder vol-
umes by gray scale ultrasonography. Radiology 1978; 128:
181-2.
7. Pederson JF. Bartrum ~ Grytter C. Residual urine de-
termination by ultrasonic scanning. Am ] Roentgenol
1975;125;474-8.
8. Griffiths CJ, Murray A, Ramsden PD. Accuracy of and
repeatability of bladder volume measurement using ul-
trasound imaging.] UroI1986;136:808-12.
9. Doust BD, Baum ]K, Maklad NF, Baum RF. Determi-
nation of organ volume by means of ultrasonic B-mode
scanning. ]CU 1974;2(2): 127-30.
10. Kiely EA, Hartnell GG, Gibson RN, Williams G. Mea-
surement of bladder volume by real-time ultrasound. Br
] Urol 1987;60:30-5.
11. Orgaz RE, Gomez AZ, Ramirez CT, Torres JLM. Appli-
cations of bladder ultrasonography. I. Bladder content
and residue.] Urol 1981; 125: 174-6.
Bound volumes of the AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY are avail-
able to subscribers (only) for the 1989 issues from the Publisher, at a cost of $56.00 ($79.00
international) for Vo!' 160 (January-June) and Vo!' 161 (July-December). Shipping charges
are included. Each bound volume contains a subject and author index and all advertising
is removed. Copies are shipped within 60 days after publication of the last issue in the
volume. The binding is durable buckram with the JOURNAL name, volume number, and
year stamped in gold on the spine. Payment must accompany all orders. Contact The C.V.
Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis,
Missouri 63146-3318, USA; phone (800) 325-4177, ext. 351.
Subscriptions must be in force to qualify. Bound volumes are not available in place
of a regular JOURNAL subscription.