Int Urogynecol J (2008) 19:603–606
DOI 10.1007/s00192-008-0568-0
EDITORIAL
The accuracy of post-void residual measurement in women
Bernard T. Haylen & Joseph Lee
Received: 15 December 2007 / Accepted: 6 January 2008 / Published online: 27 February 2008
# International Urogynecology Journal 2008
Introduction
Post-void residual (PVR) is defined as the volume of fluid
remaining in the bladder at the completion of micturition
[1, 2]. Some of the forefathers of urodynamic methodology,
represented in the authorship of Ref. [1], established the
goal of optimal accuracy for the measurement of all
urodynamic parameters. Thirty years later, the need for
accuracy in measuring the PVR, a key indicator of bladder
function, has yet to gain its due recognition. Accuracy and
calibration in relation to pressure measurement, bladder
filling, and uroflowmetry have been embraced, though the
same cannot be said for the accuracy of PVR measurement.
PVR measurement methodology has considerable vari-
ation [3–6] matched by similar variation in the results of
scientific studies on this parameter [3–7]. In many other
PVR studies, the exact methodology is either unclear or not
validated or both. No details are often given of the mean
time the PVR measurement has occurred post-micturition
and if urethral catheterization was used, the type of catheter,
and whether this was uniform for all the studies.
The main source of error is likely to be the additional
renal input into bladder volume from the delay in PVR
measurement following micturition leading to an overesti-
mation. Two factors can be multiplied to determine this
input: (1) the diuresis (ml/min) occurring at the time and (2)
the duration of the delay (min) between completion of
micturition and PVR measurement (if the latter is by
B. T. Haylen (*) : J. Lee
St Vincent’s Clinic,
Suite 904, 438 Victoria Street,
Darlinghurst 2010 N.S.W., Australia
e-mail: haylen@optusnet.com.au
urethral catheterization, the end-point of the delay is the
completion of bladder drainage). If both are excessive, the
overestimation can be marked. This “diuresis factor” can, at
times, be significant clinically; scientific studies of PVRs
need to take this into consideration. Other sources of error
apply to (1) the adequacy of bladder drainage and the
accuracy of measuring apparatus if catheterization is used;
(2) the relative levels of accuracy of the different ultrasound
techniques at different bladder volumes.
Diuresis factor
Data has been published [8] relating to the diuretic
responses of women to two fluid loads of 1,000 ml and
500 ml. Figures 1 and 2 show the bladder-filling rates
(medians and interquartile range—25th and 75th centiles)
from 20 min prior to the fluid load to 160 min following the
fluid load for each group of 20 women. Figures 1 and 2
might then be used as a guide to determine the diuresis rates
following fluid loads of 500 ml to 1,000 ml and up to
500 ml, respectively (to our knowledge there exists no other
equivalent study).
Interpretation and examples of the diuresis factor
The possible impact of the “diuresis factor” on PVR
measurement might be gauged by multiplying (1) the stated
(Fig. 1 or 2 depending on the amount of fluid load) diuretic
level at a particular time interval after the fluid load by (2)
the time interval (delay) between voiding and PVR
measurement. From the examples below, significant over-
estimations can occur if the delay is extended.
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A PVR of 80 ml after a 500-ml fluid load, consumed
80 min previously (median diuresis is 4 ml per minute—
Fig. 2), might really be only 48 ml if the delay between
voiding and PVR measurement is 8 min. The overestima-
tion is 32 ml (67%). Similarly, a PVR of 140 ml taken
60 min after a 1,000-ml fluid load (median diuresis is 9 ml
per minute—Fig. 1) might be only 50 ml if the delay
between voiding and PVR measurement is 10 min. The
maximal overestimation might be 90-ml (180%). However,
at the 75th centiles, where the respective diureses would be
6 ml/min and 12 ml/min, the true (immediate) PVRs in
these examples would be 32 ml and 20 ml and the over-
estimations would be 48 ml (150%) and 120 ml (600%),
respectively.
Clinical relevance of the diuresis factor
PVR measurement is essential in all urogynecological
assessments, particularly in the identification or elimination
of the diagnosis of voiding difficulty (abnormally slow and/
or incomplete voiding) prior to surgical intervention for
urodynamic stress incontinence. A high PVR will generally
need confirmation by repeat measurement and may alter
clinical management; a low PVR is reassuring. To avoid an
overestimation of the PVR, it is best to minimize any
diuresis factor. Clinically, especially in the urodynamic
laboratory, the delay should be minimized between voiding
and PVR measurement: ultrasonic techniques can measure
PVRs within 60 s of voiding [9, 10]; PVR measurement by
urethral catheterization can be achieved efficiently within
5 min of voiding [8, 10] or inefficiently up to 10–16 min
Fig. 1 Bladder-filling rates (medians and interquartile ranges) in 20
women before and after a 1,000-ml fluid load. Reproduced with
permission from [8], Wiley-Blackwell, Oxford, UK
Int Urogynecol J (2008) 19:603–606
Fig. 2 Bladder-filling rates (medians and interquartile ranges) in 20
women before and after a 500-ml fluid load. Reproduced with
permission from [8], Wiley-Blackwell, Oxford, UK
[10]. In the hospital postoperative situation, effective drain-
age of suprapubic catheters can occur within 5 min [11].
Academic relevance of the diuresis factor
Academically, studies taking 10 min to achieve PVR
measurement, independent of the methodology, are at risk
of variable and possibly significant overestimation of the
PVR. If methodology involves a significant delay in PVR
measurement, on strict scientific terms, the following need
to be determined (1) the length of the delay; (2) the timing
and the amount of prior fluid intake; (3) a likely diuresis
applicable at the time of PVR measurement (perhaps by the
median values of Figs. 1 and 2 for volumes, respectively
500–1,000 ml and up to 500 ml); (4) a correction of the
PVR measurement for the bladder filling during the delay.
Failing to make these corrections results in a study of
delayed (10-min) post-void residuals not (immediate) post-
void residuals, as required by the definition [1, 2].
The wide variation in the recommended upper limit of
“normal” PVR in different PVR studies of symptomatic
women, from 30 ml [3] to 50 ml [4], 100 ml [5], 150 ml [7]
and 200 ml [12], creates clinical uncertainty. In asymptom-
atic women, the level up to which 95% PVRs occur has
also varied between 30 ml [13] and 100 ml [6]. The
“diuresis factor” may be relevant to the results from these
different techniques: (1) transvaginal ultrasound [3, 13]; (2)
transabdominal ultrasound [6] and (3) urethral catheteriza-
tion [4, 5, 7]. Different “delays” are quoted from 60 s maxi-
mum [3, 13] to 10 min maximum [4, 6]. The lowest upper
limit of normal PVRs in both symptomatic and asymptom-
atic women have been noted when the “diuresis” factor has
Int Urogynecol J (2008) 19:603–606
been minimized [3, 13], in line with the above PVR defini-
tion, using transvaginal ultrasound within 60 s of voiding.
Catheter and measurement apparatus factors
(PVR measurement by urethral catheterization)
For PVR measurement by urethral catheterization, the use of
a catheter which incompletely drains the bladder will lead to
an underestimation of the true PVR. A short plastic catheter
(particularly a 14FG though a 12FG is probably also
adequate), will make sure [11] that whatever PVR is present
will be completely drained (under 1 ml post-catheterization
bladder volume). A 14FG Foley urethral catheter will leave,
on average, 77 ml of post-catheterization bladder volume
[11]. Smaller Foley catheters than 14FG can be expected to
have an even higher post-catheterization bladder volume.
It is a quoted practice to enhance the drainage of a Foley
catheter by suction drainage using a syringe. Whilst there is
weak evidence that this might be helpful [14], the efficacy
of this technique has not been proven. Similarly, small bore
urodynamic filling catheters have been used to drain the
bladder, though this may be relatively slow, thus increasing
the delay in collection. There are no published data to
confirm their efficacy in bladder drainage.
Presuming the PVR collection occurs without delay, a
catheter with known efficacy in bladder drainage is used
and there is no PVR spillage, one has to rely on the
accuracy of the measuring apparatus used which might
have variable and often inappropriate (for the volume) and
inaccurate calibration.
Accuracy of ultrasound for PVR measurement
Good urodynamic practice should progress into the 21st
century by attempting to reduce or eliminate potential
sources of error in PVR measurement. This implies mini-
mizing the diuresis factor and seeking to overcome any
catheter and apparatus factors. Ultrasound techniques of
known accuracy offer the best prospects of achieving these
aims, cost considerations allowing. There are, of course,
known benefits to patients [10] of reduced psychological
stress and possible physical problems (urinary tract infec-
tions, urethral trauma, and hematuria). The benefits of
ultrasound for PVR measurement (known accuracy, re-
duced time and patient trauma) need to be added to the
increasing array of other indications for ultrasound in
urogynecology (bladder neck assessment and intercurrent
lower urinary tract and pelvic floor pathology, etc. [15])
when equipment costs are being considered. With ultra-
sound, all women with any PVR have the opportunity of a
second attempt to reduce or clear this volume. This might
605
avoid the need for subsequent repeat PVR measurements if
surgery was being contemplated in a patient with an abnor-
mally high PVR measured using urethral catheterization.
The use of abdominal ultrasound to measure bladder
volumes dates back to 1967 [16]. Different formulae have
been used generally, using three bladder diameters, height,
width, and depth (generally multiplied by a constant, with
0.625 commonly used—[17]). Results have been variable
and conflicting [17] with accuracies limited by the
variability in bladder shape and filling [18]. Accuracies in
most published series are around 21%–25% [16–18]. The
key limitation of transabdominal ultrasound is the distance
between the abdominal wall and the bladder, with fat
(obesity), gas, and bone (shadowing of the pubis) potential
impediments to the transmission of the sound beam.
Smaller bladder volumes (under 100 ml) have been cited
as more difficult to quantify with false negatives occurring
under 50 ml [17]. Advances in ultrasound technology will
have improved visualization over time.
Transvaginal ultrasound, first reported in 1989 [9],
involves the calculation of bladder volumes using two
bladder dimensions in the sagittal plane. It has been shown
to provide accurate and validated [19] measurements of
PVRs from 0 ml to 175 ml with superior visualization of
PVR under 30 ml, where around 80% to 90% of PVR appear
likely to occur [3]. Accuracy is 24% (overall) and 15%
(volumes 50 ml and over). Under 50 ml, the accuracy rises to
55%. Transrectal ultrasound was also reported in 1989 [20],
using similar methodology to that for transvaginal ultrasound
with a mean accuracy of 16%. Although its calibration was
done only in men, it is possible to measure PVRs in women
accurately using this modality. The accuracy of transperineal
(translabial) ultrasound in PVR measurement needs to be
researched. This modality is already used widely in
urogynecology [15], with perhaps less specialized probes
than used with transvaginal or transrectal ultrasound.
An alternate form of abdominal ultrasound, Doppler
planimetry, has gained popularity in measuring PVRs.
Commercial application had started in 1986 [10], with an
early report in 1994 [21]. The systems are small and
portable with the technique for use quickly learned. Cross-
sectional planes of the bladder are measured at 15-degree
angular increments with the computer software constructing
a three-dimensional model of the bladder from which
volume is determined. This form of PVR assessment has
been shown to be accurate within 15% of bladder volumes
as measured by urethral catheter within the range 0–999 ml
[6, 22]. Reported limitations on its use are serious
abdominal scars, uterine prolapse, and pregnancy [10, 22]
with false positives in cases of pelvic cysts [23].
Overall correlation of more recent models of Doppler
planimetry, the BME-150A (S & D Medicare Co., Seoul,
Korea) and BladderScan BVI 3000 (Diagnostic Ultrasound
606
Co., Bothell, WA, USA) with catheterized bladder volumes
(12FG latex rubber urethral catheter) were 0.92 and 0.94,
respectively, with a mean difference from true residual
volume of 7.8 ml and 3.6 ml [23]. Whilst both scanners
were reported [23] to have good accuracy at low bladder
volumes, like previous studies, exact sensitivities and
accuracies for volumes fewer than 100 ml have not been
reported. Both types of bladder scanners do not have the
other applications of conventional transabdominal, trans-
vaginal, and transperineal ultrasound.
Accuracy of other techniques for PVR measurement
Not discussed here are those other possible methods of
PVR assessment such as abdominal palpation and bimanual
pelvic examination, which are imprecise. Radiology and
radionucleotide scans have not gained favor as these
techniques are more invasive, carry additional risks and
also impractical in the settings outlined.
Conclusions
The PVR is a key marker of bladder function in terms of
emptying ability. The accurate measurement of PVR needs
to advance as a clinical and academic priority. Ultrasound
assessment has the greatest ability to eliminate the sources
of error from urethral catheterization, particularly the
“diuresis” factor. The many advantages of such an ultra-
sonic PVR measurement should be added to the benefits of
the other applications of ultrasound in urogynecology.
This commentary does not decry the use of urethral
catheterization for PVR measurement. This form of
measurement will be the mainstay of clinical practice for
some time to come. However, it highlights the many
sources of potential error in the accuracy of PVR
measurement that can’t just be ignored clinically and
particularly in scientific publications. Submissions in
relation to PVR measurement failing to give a detailed
outline and/or to optimize the accuracy of their methodol-
ogy should be vulnerable to appropriate criticism. More
studies are needed on optimizing the accuracy of PVR
measurement by urethral catheterization, principally by
minimizing the diuresis factor, so that it might be
equivalent to ultrasonic techniques [24].
References
1. Bates P, Glen E, Griffiths D et al (1977) Second report on the
standardization of terminology of lower urinary tract function.
Scand J Urol Nephrol 11:197–199
Int Urogynecol J (2008) 19:603–606
2. Abrams P, Cardozo L, Fall M et al (2002) The standardisation of
terminology of lower urinary tract function. report from the
standardisation subcommittee of the International Continence
Society. Neurourol Urodyn 21:167–178
3. Haylen BT, Law MG, Frazer MI, Schulz S (1999) Urine flow rates
and residual urine volumes in urogynaecology patients. Int
Urogynecol J 10:378–381
4. Costantini E, Mearini E, Panjoncini C et al (2003) Uroflowmetry
in female voiding disturbances. Neurourol Urodyn 22:569–573
5. Lukacz ES, DuHamel E, Menefee SA, Luber KM (2006) Elevated
postvoid residual in women with pelvic floor disorders: Preva-
lence and associated risk factors. Int Urogynecol J 18:397–400
6. Gehrich A, Stany MP, Fischer JR et al (2007) Establishing a mean
postvoid residual volume in asymptomatic perimenopausal and
postmenopausal women. Obstet Gynecol 110(4):827–830
7. Dwyer PL, Desmedt E (1994) Impaired bladder emptying in
women. Aust NZ J Obstet Gynaecol 34(1):73–78
8. Haylen BT, Frazer MI, Sutherst JR, Ashby D (1989) The accuracy
of measurement of residual urine volumes in women by urethral
catheterization. Brit J Urol 63:152–154
9. Haylen BT, Frazer MI, Sutherst JR, West CR (1989) Transvaginal
ultrasound in the assessment of bladder volumes in women.
Preliminary report. Br J Urol 64:149–151
10. Teng C-H, Huang Y-H, Kuo B-J, Bih L-I (2005) Application of
portable ultrasound scanners in the measurement of post-void
residual urine. J Nurs Res 13:216–223
11. Haylen BT, Frazer MI, MacDonald JH (1989) Assessing the
effectiveness of different urinary catheters in emptying the bladder:
an application of transvaginal ultrasound. Brit J Urol 64:353–356
12. U.S. Department of Health and Human Services, Public Health
Service, Agency for Health Care Policy and Research (1992)
Clinical practice guidelines: urinary incontinence in adults. U.S.
Department of Health and Human Services, Washington, DC
13. Haylen BT (1989) Residual urine volumes in a normal female popu-
lation: application of transvaginal ultrasound. Br J Urol 64:347–349
14. Stoller ML, Millard RJ (1989) The accuracy of catheterized
residual urine. J Urol 141:15–16
15. Tunn R, Schaer G, Peschers U et al (2005) Updated recommen-
dations on ultrasonography in urogynecology. Int Urogynecol J 16
(3):236–241
16. Holmes JH (1967) Ultrasonic studies of the bladder. J Urol
97:684–691
17. Hakenberg OW, Ryall RL, Langlois SL, Marshall VR (1983) The
estimation of bladder volume by sonocystography. J Urol
130:249–252
18. Keily EA, Hartnell GG, Gibson RN, Williams G (1987) Measure-
ment of bladder volume by real-time ultrasound. Brit J Urol 60:33–35
19. Haylen BT (1989) Verification of the accuracy and range of
transvaginal ultrasound in measuring bladder volumes in women.
Brit J Urol 64:350–352
20. Haylen BT, Parys BT, West CR (1989) Transrectal ultrasound in
the measurement of residual urine volumes in men. Neurourol
Urodyn 8:327–328
21. Coombes GM, Millard RJ (1996) The accuracy of portable
ultrasound scanning in the measurement of postvoid residual
urine volume. J Urol 152:2083–2085
22. Goode PS, Locher JL, Bryant RL et al (2000) Measurement of post-
void residual urine with portable transabdominal bladder ultrasound
scanner and urethral catheterization. Int Urogynaecol J 11:296–300
23. Choe JH, Lee JY, Lee K-S (2007) Accuracy and precision of a
new portable ultrasound scanner, the BME-150A, in residual urine
volume measurement: a comparison with the BladderScan BV1
3000. Int Urogynecol J 18:641–644
24. Haylen BT, Frazer MI (1994) Measurement of residual urine
volumes in women: urethral catheterization or transvaginal
ultrasound. Int Urogynecol J 5:269–272