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Article

Effect of Premicturitional Bladder

Volume on the Accuracy of Postvoid
Residual Urine Volume Measurement
by Transabdominal Ultrasonography
Rate of Bladder Fullness Is of Great Importance
for Preventing False-Positive Residue Diagnosis

Eriz Özden, MD, Ahmet T. Turgut, MD, Çagatay Gögüs, MD,

Ugur Kosar, MD, Sümer Baltaci, MD

Objective. The purpose of this study was to evaluate the effect of premicturitional bladder volume
(V1) on postvoid residual urine volume (V2) measurements and to assess the ideal V1 for an accurate
V2 determination. Methods. Twenty-five healthy men without any urinary symptoms constituted the
study group. Measurements by transabdominal ultrasonography for V1 and V2 were performed for
each subject at 3 different phases, each of which was preceded by oral intake of 1000 mL of water
and accompanied by “mild,” “moderate,” and “severe” sensations of micturition, respectively.
Results. Mean ± SD V1 and V2 during the first, second, and third phases were 117.7 ± 70.3 and 1 ±
1, 356.2 ± 112.3 and 11.5 ± 12 and 639.6 ± 171.8 and 58.8 ± 35.2 mL, respectively. With 50 mL as
the cutoff value for a pathologic V2, 15 (60%) men had V2 in the third phase exceeding this value,
whereas the same rate was calculated as 0% for either of the first 2 phases. No patient with V1 of less
than 540 mL had V2 of greater than 50 mL. Conclusions. Postvoid residual urine volume measure-
ments with an uncomfortably full bladder result in high false-positive postmicturitional residue values
even in healthy young men. We strongly advise that V1 measurements of the bladder be performed
before V2 measurements and that V2 not be measured if V1 is greater than 540 mL. Key words: blad-
der; residual volume; ultrasonography.

T
Abbreviations
LUTS, lower urinary tract symptoms; PVR, postvoid
residual urine; V1, premicturitional bladder volume; V2,
postvoid residual urine volume
Received January 6, 2006, from the Department of
Urology, School of Medicine, Ankara University,
Ankara, Turkey (E.Ö., Ç.G., S.B.); and Department
of Radiology, Ankara Training and Research
Hospital, Ankara, Turkey (A.T.T., U.K.). Revision
requested February 13, 2006. Revised manuscript
accepted for publication March 9, 2006.
Address correspondence to Eriz Özden, MD,
Ankara Üniversitesi Tip Fakültesi Ibni Sina Hastanesi,
TR-06100 Ankara, Turkey.
E-mail: erizozden@yahoo.com
he accurate determination of postvoid residual
urine (PVR) volume (V2) is an important factor for
diagnosing voiding dysfunction and for making a
decision regarding the treatment options in the
management of benign prostatic hyperplasia.1,2 On the
other hand, accurate PVR measurements are important
for the diagnosis and follow-up of patients with lower
urinary tract symptoms (LUTS).3,4 Although urethral
catheterization is accepted as the standard for PVR mea-
surements, ultrasonography is easier to perform and has
a lower morbidity rate.5–8 In addition, ultrasonography
has been reported to have high sensitivity and specificity
for the estimation of PVR.9 The patients whose PVR will
be measured are advised to drink a considerable amount

© 2006 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 2006; 25:831–834 • 0278-4297/06/$3.50
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Premicturitional Bladder Volume and Postvoid Residual Urine Volume
of fluid before the examination and to micturate
when they have a moderate to severe need to
void.10,11 Alivizatos et al10 stated that this is not a
realistic situation, and such a fluid intake may
stress and temporarily decompensate the blad-
der and cause unreliable PVR measurements in
patients with benign prostatic hyperplasia.
In this study, we hypothesized that PVR mea-
surements performed with an overly full bladder
do not represent normal, daily micturition situa-
tions and that a distended bladder may cause
high false-positive PVR values even in healthy
men. We sought to evaluate the effect of premic-
turitional bladder volume (V1) on V2 measure-
ments. In addition, we assessed the limits of V1
for preventing false-positive V2 determinations.
Materials and Methods
In this prospective study, 25 healthy men without
any LUTS and with normal uroflowmetric
parameters constituted the study group. The
studied uroflowmetric parameters were maxi-
mum flow rate, average flow rate, and time to
maximum flow. None of the patients had been
receiving any medical therapy. This study was
approved by the Institutional Ethics Committee,
and informed consent was obtained from all
patients. The examination of the patients was
performed in 3 phases, before which each
patient ingested 1000 mL of water in 30 minutes
to distend the bladder.
In the first phase of the study, the patients void-
ed at a mild sensation of micturition. In the sec-
ond phase, the patients voided at a moderate
sensation of micturition, and in the third phase,
the patients voided at a severe sensation of mic-
turition. For all 3 phases, premicturitional and
postmicturitional bladder volumes were mea-
sured by transabdominal ultrasonography
immediately before and after micturition by
using the formula described by Poston et al12
(height × depth × width × 0.7). A radiologist with
uroradiology experience (A.T.T.) performed all
ultrasonographic examinations with an SDU-
2200 color Doppler ultrasonographic scanner
(Shimadzu Corporation, Kyoto, Japan) equipped
with a 2- to 5.5-MHz convex probe. Increased
PVR was defined as a volume of 50 mL or greater6
immediately after micturition. A paired samples
t test was used to examine the difference
between V1 and V2. P < .05 was considered statis-
tically significant.
832
Results
The mean age of the patients ± SD was 38.4 ± 9.9
years. The mean periods from the beginning of
ingestion of water to voiding were 35 ± 5 minutes
for the first phase, 54 ± 12 minutes for the second
phase, and 75 ± 22 for the third phase of the
study.
Mean V1 and V2 in regard to the aforementioned
phases of the study are given in Table 1. By statis-
tical comparison, mean V1 and V2 values for each
step were significantly different (P < .001 for
each). By accepting 50 mL as the cutoff value for
a pathologic V2, 15 (60%) of the healthy men had
V2 in the third phase exceeding this value, where-
as the same rate was calculated as 0% for either of
the first 2 phases. In addition, no patient with V1
of less than 540 mL had V2 of greater than 50 mL.
Discussion
It has been reported that PVR can be associated
with upper urinary tract problems such as
hydronephrosis, recurrent urinary tract infec-
tions, and bladder calculi and may contribute to
urinary frequency and nocturia because bladder
capacity is functionally decreased due to retained
urine.13 In this regard, accurate PVR measure-
ments are important for the diagnosis and follow-
up of patients with LUTS.3,4 It has also been
reported that men with a PVR value of greater
than 50 mL were 3 times more likely to have acute
urinary retention during the 3-year follow-up.11
Hence, the presence of a large PVR volume has
been reported to be a common indicator for
transurethral resection of the prostate.14
On the other hand, urethral catheterization has
been accepted as the standard for PVR measure-
ment.5,6 Although some studies suggest poor
correlation between the bladder volumes pre-
dicted by ultrasonography and those obtained
by urethral catheterization, ultrasonography is
a reliable, noninvasive, inexpensive, and simple
method that has been used extensively for this
purpose.6–10
In clinical practice, patients whose PVR will be
measured are advised to drink a considerable
amount of fluid before the examination and to
urinate when they experience a moderate to
severe desire to void.10,11 Therefore, we hypothe-
sized that PVR measurements performed with a
full bladder may not represent normal micturi-
tion situations, and a distended bladder may
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vol22_no7_jum_online.q 6/16/06 10:50 AM Page 833
cause high false-positive PVR values. In our
review of the literature, we found only 1 study
that focused on this topic. Alivizatos et al10 tested
the consistency of PVR measurements when the
bladder was filled to maximum capacity after an
increased water load and PVR measurements
after the bladder was filled under normal cir-
cumstances in which the patients emptied their
bladders at the first desire to void. Accordingly,
the mean PVR value was 195 mL when the
patients voided after a full bladder, with a mean
V1 of 410 mL. On the other hand, the mean PVR
value was 41 mL when they voided after the first
desire to void, with a mean V1 of 120 mL. The
authors concluded that high premicturitional
bladder volumes do not represent realistic situa-
tions, and the correct method of testing should
be to measure the PVR value when the patient
voids at the first desire. Our study differs from
theirs in 2 major respects. First, the study by
Alivizatos et al10 was performed on men (mean
age, 69.6 years) with symptoms of LUTS. Our
study group consisted of healthy men (mean
age, 38.4 years) with no urologic conditions or
symptoms. In addition, we added a third phase,
the moderate sense of micturition, between the
mild and severe sensations of micturition and
tried to determine the lowest premicturitional
bladder capacity that causes high false-positive
PVR measurements.
Our findings revealed that healthy young men
had a mean V1 of 117.7 mL when they had the first
mild sensation of micturition, and the mean V2
was 1 mL at this phase. When the same patients
voided after the moderate sensation of micturi-
tion, the mean V1 was 356 mL, and V2 was 11.5
mL; however, at the third phase of the study in
which the patients voided after the severe sensa-
tion of micturition, the mean V1 was 639 mL,
whereas the mean V2 was 58.8 mL. By accepting
50 mL as the pathologic PVR value, 15 (60%)
healthy men had V2 in the third phase exceeding
this value, whereas the same rate was 0% for
either of the first 2 phases. These results clearly
show that even in healthy young men with no
LUTS, high premicturitional bladder volumes
cause high false-positive PVR values. In our study
group, 15 (60%) healthy men who had normal
PVR values after voiding at mild or moderate sen-
sations of micturition had a pathologic PVR value
when they voided after a very full bladder.
Moreover, it has been stated by Blanker et al15 that
people often void before the maximum bladder
J Ultrasound Med 2006; 25:831–834
Özden et al
Table 1. Mean V1 and V2 in Regard to Phases of the Study Labeled
According to Degree of Sensation of Micturition
Volume, mL Phase 1 (Mild) Phase 2 (Moderate) Phase 3 (Severe)
V1 117.7 ± 70.3 356.2 ± 112.3 639.6 ± 171.8
V2 1±1 11.5 ± 12 58.8 ± 35.2
Values are mean ± SD
capacity has been reached. This also indicates
that PVR measurements should be performed
before the severe sensation of micturition.
Milleman et al13 stated that PVR represents the
summation effect of the functions of the bladder
and urethral sphincter mechanism. In our study,
there was no pathologic PVR noted after the first
and second phases of this study; therefore, the
PVR values greater than 50 mL are possibly a
result of acutely stressed and temporarily
decompensated detrusor muscles secondary to
the overly distended bladder, as stated by
Alivizatos et al.10 We agree with the authors’ com-
ment that high PVR values measured after a very
full bladder represent an acute decompensation
of the detrusor muscle.10
Our findings are basically in accordance with
those of Alivizatos et al,10 but those authors have
also stated that the measurement of PVR in a
patient should be performed at the first desire to
void. On the other hand, the least mandatory pre-
voiding bladder volume for useful uroflowmetry
was determined to be 200 mL16; however, in our
study, the mean V1 calculated before the first sen-
sation to void was 117.7 mL. Thus, contrary to
Alivizatos et al,10 we think that PVR values calcu-
lated after the first sensation to void will not be
enough and may also cause unreliable results.
None of the subjects in our study had a PVR
value of greater than 50 mL when they micturat-
ed at the moderate sense of micturition, and at
this phase, the mean V1 was calculated to be 356
mL. In addition, our results showed that no
patient with a V1 of less than 540 mL had a PVR
value exceeding 50 mL. Hence, the optimum
timing to measure PVR seems to be at the mod-
erate feeling of micturition; however, this feeling
may be highly variable as well. In a previous
study, Dicuio et al16 proposed prevoiding bladder
ultrasonography for determination of at least a
200-mL bladder volume for a useful uroflowme-
try test. We likewise propose the measurement of
premicturitional bladder volume by ultrasonog-
raphy and for performing PVR measurements if
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Premicturitional Bladder Volume and Postvoid Residual Urine Volume

the V1 is greater than 540 mL. Of course, our study
group consisted of healthy young men, and the
optimum bladder volume before PVR measure-
ments may differ for patients with LUTS. In addi-
tion, as stated by Benacerraf,17 consideration
must be given to the extreme discomfort experi-
enced by patients who have to wait to maintain a
full bladder, and our results suggest that this dis-
comfort is unnecessary because a moderate sen-
sation of bladder fullness is adequate for PVR
measurements.
In conclusion, PVR measurements with an
uncomfortably full bladder cause high patholog-
ic PVR values even in healthy men. To prevent
false-positive PVR diagnoses, patients must have
only a moderate sense of micturition before the
measurement. We propose that a reliable PVR
measurement should be performed after pre-
micturitional measurement of bladder volume
by ultrasonography that does not exceed 540 mL.
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