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JOURNAL COMPILATION 2009 BJU INTERNATIONAL

Lower Urinary Tract
DETRUSOR WALL THICKNESS AS A TEST FOR DETRUSOR OVERACTIVITY IN WOMEN WITH OAB
CHUNG

et al.

Transabdominal ultrasonography of detrusor

BJUI BJU INTERNATIONAL
wall thickness in women with overactive bladder
Shiu-Dong Chung, Bin Chiu, Hann-Chorng Kuo*, Yao-Chi Chuang,
Chung-Cheng Wang, Zhonghong Guan and Michael B. Chancellor
Division of Urology, Department of Surgery, Far Eastern Memorial Hospital, Ban Ciao, Taipei, *Department of Urology,
Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Department of Urology, Chang Gung Memorial
Hospital, Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Division of Urology,
Department of Surgery, En Chu-Kong Hospital, Taipei, Taiwan, Pfizer Incorporated, New York, NY, and Department
of Urology, William Beaumont Hospital, Royal Oak, MI, USA
Accepted for publication 29 May 2009

Study Type Diagnostic (case series)
Level of Evidence 4
OBJECTIVE
To determine the clinical usefulness of
measuring detrusor wall thickness (DWT) as
a noninvasive test in women with overactive
bladder (OAB).
PATIENTS, SUBJECTS AND METHODS
We prospectively enrolled 122 women with
dry OAB, wet OAB, and women with no OAB
symptoms (control group). A 3-day voiding
diary was used to differentiate between
wet and dry OAB. Transabdominal
ultrasonography (TAUS) measurements of
DWT were taken at bladder volumes of
250300 mL and the maximal bladder
capacity by both catheter- and natural-
filling. Video-urodynamic studies (VUDS)
were used to classify bladder dysfunction in
88 of the women.
RESULTS
The mean (range) age of the women was
58 (2094) years. There were 39 normal
controls, 44 women had dry OAB, and 39 had
wet OAB. Of the 88 women who had VUDS,
28 had a normal test, 30 had increased
bladder sensation (IBS), and 30 had detrusor
overactivity (DO). The mean DWT at
250300 mL among three symptomatic
subgroups or urodynamic subgroups
showed no significant difference by either
catheter- or natural-filling methods. The
women with wet OAB had significantly
greater DWTs than the controls at maximal
bladder volume. The maximal bladder
capacity was significantly greater in normal
women than in those with OAB. If we
corrected maximal bladder volume to
250 mL, DWT at corrected 250 mL showed
no significant difference among three
symptomatic subgroups.
CONCLUSIONS
DWT measured by TAUS in women with OAB
and without OAB was not different and
did not differ with urodynamic status.
Thus, TAUS measurement of DWT is not
recommended as a useful diagnostic test for
DO in women with OAB.
KEYWORDS
bladder wall, overactive bladder, ultrasound,
urodynamics

INTRODUCTION
Overactive bladder (OAB), defined as the
symptoms of urgency, with or without
urgency urinary incontinence, usually with
frequency and nocturia by the ICS, is highly
prevalent in women [1,2]. However, OAB is
diagnosed based on LUTS reported by patients
[2]. Although we can use urodynamic studies
to verify the presence of detrusor overactivity
(DO), about half of all patients with OAB do
not have DO during urodynamic studies [3].
Therefore, searching for a biomarker to
identifying true DO is important. Detrusor
wall thickness (DWT) has been noted to be
increased in men with BOO and children with
bladder-induced enuresis [4,5]. The detrusor is
thought to increase in weight after the long-
term increased workload due to BOO [4]. As
DO induces frequent detrusor contractions
during the bladder filling phase, it is possible
that the detrusor also increases in thickness
and volume in patients with OAB.
Previous studies have shown that
transabdominal ultrasonographic (TAUS)
measurement of bladder wall thickness (BWT)
using a high frequency US probe (8 MHz) has
low inter- or intra-observer variation [6,7].
Also, the DWT decreases in thickness with
increased bladder volume [6,7]. Therefore,
it would be useful to determine whether
patients with OAB may have a greater DWT
compared with control subjects with no OAB.
However, previous studies have used a
constant bladder volume by infusing normal
saline through a catheter [68]. If we could
determine an equation or method to calculate
DWT measured at different bladder volumes
during natural diuresis, then this would
provide a more practical method for
widespread application of this test as a
biomarker for screening patients for DO in
women with OAB.
The present study was designed to determine
the relationship between bladder volume and
DWT in women with OAB. By measuring DWT
at different bladder volumes, an estimate of
the variance in DWT could be determined as
measured using natural- vs catheterized-

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668 JOURNAL COMPILATION 2 0 0 9 B J U I N T E R N A T I O N A L | 1 0 5 , 6 6 8 6 7 2 | doi:10.1111/j.1464-410X.2009.08927.x
 DETRUSOR WALL THICKNESS AS A TEST FOR DETRUSOR OVERACTIVITY IN WOMEN WITH OAB
FIG. 1. DWT measurement by TAUS. The perivesical
tissue, mucosa, and submucosal tissue appear
hyperechogenic (bright), the detrusor appears
hypoechogenic (dark). The DWT measurements were
made at three different sites along the wall.
filling. The main objective of the present study
was to determine if DWT in women with OAB
was greater than that of controls, either by
natural- or catheterized-filling. Thus, the
results of the present study could provide
the methodology for the noninvasive
measurement of DWT for the study of
progression in OAB.
PATIENTS, SUBJECTS AND METHODS
Women with dry OAB, wet OAB, and women
with no symptoms of OAB (control group)
were enrolled in the present study. A 3-day
voiding diary was used to differentiate
between wet and dry OAB. Patient eligibility
necessitated no previous bladder or urethral
surgery, active UTI, neurogenic lesions, or
postvoid residual urine volume (PVR) of
>50 mL. All the women underwent TAUS of
the bladder using an 8.0-MHz transducer (E8C
probe; GE, USA) and GE US equipment (Logic-
Q P5/A5). Each woman underwent natural-
and catheter-filling TAUS determinations of
DWT. All subjects were offered a video
pressure-flow study (PFS). A catheter-filling
DWT measurement was performed during the
filling phase of the videourodynamic study
(VUDS) in 88 women. All women had both
natural- and catheter-filling to investigate
the difference in DWT results between the
two methods of filling. Natural-filling was
performed first followed by catheter-filling,
so that subjects could complete the study
within one visit. The two DWT measurements
were performed on the same day in the same
order.
For the present study, a high quality US
scanner with digital archiving was used. The
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JOURNAL COMPILATION 2009 BJU INTERNATIONAL
desired features included compounding,
zoom function, and edge enhancement. The
transducer probe was linear with a centre
frequency of 8.0 MHz. With women lying
supine, TAUS was performed using the high-
frequency linear array. The transducer was
placed suprapubically and manipulated until
the bladder wall edges were clearly visualized
on the monitor. At low magnification, the
anatomical structures of the anterior
abdominal wall and the bladder wall were
identified. Using the zoom function, the layers
of the bladder wall were apparent. The
perivesical tissue, mucosa, and submucosal
tissue appear hyperechogenic (bright), and
the detrusor appears hypoechogenic (dark).
The transducer was manipulated to obtain the
maximum delineation and ensure that the
beam was perpendicular to the wall. The
bladder wall images were recorded and the
DWT measurements were made at three
different sites along the wall (Fig. 1). The
average of the three measurements was used
for the DWT value at that bladder volume.
For natural-filling and measuring DWT, the
women voided freely and the TAUS bladder
volume measurement was used to show a
PVR of <50 mL. The subjects were then were
asked to drink 5001000 mL of water and
wait 15 min in a sitting or semi-recumbent
position. Measurement of the DWT and total
bladder volume was performed by TAUS
every 15 min for a total of at least three
measurements until the patient had a strong
desire to void. Bladder volume measured by
TAUS was calculated for approximation of
the ellipsoid and based on the equation of:
/6 (widest diameter in the transverse
scan) (anterior-posterior diameter in the
longitudinal scan) (cephalocaudal diameter
in the longitudinal scan) [9]. After completion
of the DWT measurements, uroflometry and
the PVR were determined by TAUS. The final
total bladder volume was calculated by the
voided volume plus PVR. The bladder volume
at each time point was further corrected by
the changes of measured bladder volume to
final bladder volume.
For catheter-filling and measuring DWT, the
women were allowed to void freely and the
PVR was measured. The women were placed
supine, a 6 F urethral catheter was placed, and
the PVR was evacuated. The urethral catheter
was connected to a three-way stopcock with
a 50-mL syringe and a 500-mL bag of normal
saline. The bladder was infused with 50 mL of
normal saline in <1 min and the DWT was
measured by transverse TAUS. Measurement
of the DWT at each 50 mL increment of
normal saline was performed until the patient
was unable to tolerate an additional volume
or 500 mL was reached. The DWT was
measured at three sites of the bladder wall in
the largest transverse sectional image. After
completion of the DWT measurement, the
catheter was removed, the patient was
allowed to void without a catheter, and the
voided volume and PVR for the total bladder
volume was recorded.
If the patient was going to undergo a
urodynamic study (PFS), the DWT was
measured concomitantly during cystometry
with an infusion rate of 50 mL/min. The
infusion was stopped in 50 mL increments
and DWT was measured until 500 mL was
reached or the patient was unable to tolerate
an additional volume. After completion
of DWT measurement, a video PFS was
performed and the voiding pressure and flow
rate were recorded. The final diagnosis was
made from the VUDS as normal bladder,
increased bladder sensation (IBS), or DO. The
urodynamic classification was made based on
the recommendations of the ICS [2].
To classify the women voiding diaries (3-day)
were used to verify dry OAB (urgency at least
once per day with no urgency incontinence)
or wet OAB (at least one episode of urgency
incontinence per 3 days); if they had no
evidence of LUTS, they were classified as
controls. The women were also classified as
normal bladder, IBS, and DO based on PFS
results.
The TAUS-measured DWT, bladder volume,
and corrected DWT, were compared among
subgroups. Measurements were compared
between subjects of the controls, and
different symptom-categorized and VUDS-
categorized subgroups. ANOVA and post hoc
analyses were used for subgroups with
P 0.05 considered to indicate statistical
significance.
RESULTS
The mean (range) age of the women was
58 (2094) years. In all, 122 women were
recruited, comprised of 39 normal controls,
44 with dry OAB, and 39 with wet OAB.
Among the 88 women who underwent a
VUDS, 28 had normal results, 30 had IBS, and
30 had DO. The mean (SD) DWT during
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C H U N G ET AL.

TABLE 1 DWT in catheter-filling (CF) and natural-filling (NF) at maximal bladder volume and corrected maximal volume to 250 mL in different symptomatic and
urodynamic groups

Mean (SD) CF-DWT (mm) at: Mean (SD) NF-DWT (mm) at:
Maximum Maximum volume Maximum Maximum volume
Group, (n) volume corrected to 250 mL volume corrected to 250 mL
Symptomatic
Control, (39) 0.720 (0.202) 0.884 (0.259) 0.780 (0.230) 0.981 (0.273)
Dry OAB, (44) 0.854 (0.324) 0.904 (0.303) 0.838 (0.235) 0.960 (0.247)
Wet OAB, (39) 0.910 (0.253) 0.968 (0.275) 0.985 (0.362) 1.05 (0.326)
ANOVA, P
Control vs dry OAB 0.076 0.389
Control vs wet OAB 0.009 0.009 0.383
Dry OAB vs wet OAB 0.081
Urodynamic
Normal bladder, 28 0.687 (0.210) 0.841 (0.261) 0.770 (0.209) 0.969 (0.219)
IBS, 30 0.770 (0.215) 0.842 (0.234) 0.710 (0.177) 0.808 (0.182)
DO, 30 0.902 (0.372) 0.933 (0.358) 1.02 (0.380) 1.07 (0.328)
ANOVA, P
Normal vs DO 0.016 0.382 0.005
IBS vs DO <0.001 <0.001 0.001

catheterized filling at a bladder volume of
250300 mL, in the control, dry OAB, and wet
OAB groups was 0.95 (0.33), 0.92 (0.33), and
0.95 (0.34) mm, respectively; and during
natural filling was 0.97 (0.29), 0.99 (0.27), and
1.04 (0.31) mm, respectively. There was no
statistically significant difference in DWT
between the control and dry or wet OAB
groups (P = 0.713 and P = 0.593, respectively).
The mean (SD) DWT in the women with
normal bladder, IBS, and DO was 0.91 (0.28),
0.85 (0.31), and 0.95 (0.42) mm, respectively,
by the catheter-filling method, and
0.95 (0.28), 0.88 (0.22), and 1.05 (0.32) mm,
respectively, by the natural-filling method.
The difference of DWT between the control
and dry or wet OAB groups was not
significant (P = 0.535 and P = 0.075,
respectively).
The actual mean maximal bladder volumes
calculated by voided volume plus PVR were
increased 33% (274 mL to 366 mL) and 42%
(302 mL to 428 mL) in catheterized- and
natural-filling studies, respectively. At the
maximal volume, the mean DWT in women
with wet OAB was significantly greater
compared with the normal controls.
Although DWT did not reach a significant level
between wet and dry OAB both in natural-
and catheterized-filling, we observed a trend
of increased DWT while symptoms emerged.
However, if we corrected the maximal bladder
volume to a volume of 250 mL, the difference
in DWT was no longer evident among the
subgroups (Table 1). As we further analysed
the women who had undergone VUDS, DWT
at maximal bladder volume in DO was
significantly greater than that of IBS or
normal bladder. However, there was no
significant difference in DWT between IBS and
normal controls for both natural- and
catheterized-filling. With correction of
maximal bladder volume to a volume of
250 mL, the significant difference in the
corrected DWT existed only between DO vs IBS
in the natural-filling study (Table 1).
DISCUSSION
OAB is a highly prevalent disorder, affecting
17% of the population and negatively
affecting quality of life [10]. Bladder wall
hypertrophy and increased bladder weight
has been found in animal studies of partial
BOO [11,12]. It has been speculated that the
detrusor contracts against increased bladder
outlet resistance, and muscle hypertrophy
and collagen deposition develop [13]. Multiple
investigators have tried to develop an easier,
office-based noninvasive diagnostic tool for
BOO by using US measurement of DWT
[68,14,15]. Oelke et al. [4,7] proposed a DWT
threshold value of >2.0 mm to predict BOO in
men. Kessler et al. [15] suggested a DWT
threshold value of >2.9 mm to diagnose male
BOO, which was categorized by a PFS.
Although several excellent reports have
evaluated the diagnostic value of DWT in male
BOO [4,6,7,15], studies investigating the
correlation between OAB from non-BOO
causes and DWT are sparse. Clinically irritative
symptoms are known to correlate with DO in
both male and female patients with OAB;
however, urodynamic testing to determine DO
is invasive, expensive, time-consuming, and
may be technically difficult. Hashim and
Abrams [16] reported that 69% of men and
44% of women with urgency (dry OAB)
had DO, while 90% of men and 58% of
women with urgency and urgency urinary
incontinence (wet OAB) had DO. The
correlation between DWT and DO or OAB in
women still needs to be elucidated. A recent
observational study by Lekskulchai and Dietz
[17] reported a statistically significant
correlation between DWT and DO, which
indicated that women with DO have a thicker
DWT measured by translabial US. However,
the low sensitivity based on receiver-
operating characteristics analysis concluded
that DWT was not a useful diagnostic tool for
DO, which contradicted previously published
studies using a threshold value of DWT
[18,19].
In the present study, we attempted to
determine whether DWT measurements could
detect and categorize the severity of OAB.
Based on the present results, bladder volume
measured by natural- or catheterized-filling

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 DETRUSOR WALL THICKNESS AS A TEST FOR DETRUSOR OVERACTIVITY IN WOMEN WITH OAB
was smaller than the final bladder volume
(calculated by the voided volume plus
PVR). There was no significant difference in
DWT at 250300 mL among the different
symptomatic or urodynamic subgroups. There
was no statistically significant difference in
DWT at 250300 mL measured between
catheterized- and natural-filling.
The present data also provided further
information that the measured DWT could be
affected by bladder volume. As the present
results showed, the mean maximal bladder
capacity of normal women was significantly
greater than that of those with OAB.
Therefore, although women with wet OAB
or DO had a significantly greater DWT at
maximal volume than that of the controls or
women with IBS, there was no significant
difference between any of the all subgroups
after correcting the maximal volume to
250 mL, except between for DO and IBS in
natural-filling. Consequently, DWT measured
by TAUS is not recommended as a biomarker
for establishing a diagnosis of DO in women.
The results of the present study contradict
previous studies using translabilal US or
transvaginal US methods [1719]. Khullar
et al. [18] reported a strong correlation
between BWT measured transvaginally in an
empty bladder and DO. Robinson et al. [19]
also reported that transvaginal US assessment
of BWT was a sensitive screening tool, which
could detect DO in women with equivocal
laboratory urodynamics. Lekskulchai and
Dietz [17] reported that the mean DWT
measured by translabial US in women with DO
was significantly greater than in women with
no DO, but the sensitivity and specificity were
not good enough to be useful in the diagnosis
of DO. This discrepancy might be attributable
to the different equipment and methods. In
addition, Yang et al. [20] reported that BWT
increased in women with LUTS, except in
women with a hypersensitive bladder, which
is similar to the present results. Blatt et al. [21]
reported that BWT did not differ in patients
with voiding dysfunction and normal
urodynamics, BOO, DO, and IBS. They reported
that the mean BWT of men with voiding
dysfunction was thicker than that of women;
however, the difference was not significant.
There was no statistically significant
difference in BWT between patients with BOO
and those with no BOO.
There are conflicting data on the utility of
DWT or BWT measurements in men and
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women as a tool to confirm DO or BOO. Most
published data confirmed a greater DWT in
men with BOO compared with controls
[4,6,7,15]. BWT tends to be greater in men
than in women with no LUTS, men with LUTS
and benign prostatic enlargement show a
moderate increase in BWT, and there was a
small significant increase in BWT with age for
both men and women [14]. We postulate
that the pathophysiology of OAB is quite
complicated, especially in women. It has been
shown that the incidence of male OAB caused
by BOO is much higher than that in women
[16,22]. In other words, a proportion of men
with OAB or DO might have occult BOO, but
most women with OAB or DO do not have
BOO. This could explain why DWT of female
OAB was not significantly greater compared
with the controls. In addition, the exact
aetiology of detrusor thickening in human is
still obscure.
TAUS measurement of BWT or DWT is widely
used by most urologists as a tool to assess
bladder condition in patients with LUTS.
However, most gynaecologists prefer a
transvaginal route. Generally, there should
be no difference between DWT and BWT.
However, TAUS measured DWT at a larger
bladder volume [4,68,15,21], whereas
transvaginal US measured DWT with an
empty bladder [1719]. The bladder volume
effect on DWT or BWT varies greatly. The
results of previous studies of DWT or BWT
in patients with BOO or DO also report
discrepant results. The possible causes
of these discrepancies might include
inconsistent bladder filling conditions or
differences in resolution of the US probe.
Reviewing previous reports, studies using a
higher frequency probe (7.5 MHz) reported a
DWT of around 12 mm [7,8,15,21], whereas
those using a low-frequency probe (25 MHz)
reported a greater DWT of 35 mm [6,14].
The present study might be criticised for the
small DWT compared with previous studies.
This discrepancy could be attributable to the
application of high-frequency US probes. In
the present study, we used an 8-MHz high-
frequency probe to measure the hypoechoic
layer of the bladder corresponding to the
DW. As the resolution power was able to
differentiate the DW from the posterior rectus
fascia, the measured DWT was much thinner
than that that would have been obtained
using a lower frequency probe. The present
results are similar to published reports, in
which the DWT was measured by a higher-
frequency probe and in which the thickness of
the DW varied from 1 to 2 mm [7,21].
The results of the present study showed that
DWT in women with wet OAB or DO was not
significantly greater than that those with
dry OAB or controls, or women with IBS or
normal bladder at a bladder volume of
250300 mL. However, the DWT at maximal
bladder volume was significantly greater in
women with wet OAB or DO compared with
the other subgroups. Because the maximal
bladder volume in women with wet OAB or
DO was significantly smaller than other
subgroups, the significantly greater DWT in
women with wet OAB or DO at maximal
bladder volume probably results from a
smaller bladder capacity. As the difference in
DWT between women with OAB and controls,
or between DO and no DO was small, we
suggest the reliability and validity of the
diagnosis of DO cannot be established by a
threshold value of DWT.
In conclusion, TAUS measured DWT was not
significantly greater in women with wet OAB
or DO at a bladder volume of 250300 mL or
at the corrected maximal bladder volume of
250 mL. Therefore, TAUS measurement of
DWT is not recommended as a useful
diagnostic test for DO in women with OAB.
CONFLICT OF INTEREST
Zhonghong Guan is an employee of Pfizer.
Source of Funding: Pfizer Inc., New York, NY,
USA.
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Correspondence: Hann-Chorng Kuo,
Department of Urology, Buddhist Tzu Chi
General Hospital, 707, Section 3, Chung Yang
Road, Hualien, Taiwan.
e-mail: hck@tzuchi.com.tw
Abbreviations: DW(T), detrusor wall
(thickness); OAB, overactive bladder;
TA(US), transabdominal (ultrasonography/
ultrasound); VUDS, video-urodynamic study;
PFS, pressure-flow study; IBS, increased
bladder sensation; DO, detrusor overactivity;
PVR, postvoid residual urine volume; BWT,
bladder wall thickness.
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