Clinical Trial of Gatch UP 45-Degree Positioning for Decreasing Post-Void Residual (PVR) Urine Volume

Bando H, Ohfuru R, Niimi S, Ikeda C, Ueyama K, Bando M, Takehisa T, Kamura K and Takehisa Y

Published on: 2024-12-02

Abstract

Current case was 88-year-old female in-patient with clinical problem of urinary tract infections (UTIs). The purpose of the study was to study clinical efficacy of Gatch UP 45-degree positioning for decreasing post-void residual (PVR). As 2-month research protocol, usual body position for lying position in February 2024, and trial of Gatch up 45-degree positioning for 1 hour twice (0900h, 1500h) every day in March. PVR urine volume was taken twice a week (8 samples/month), measured, analyzed, and were included for 2 months. As a result, PVR decreased significantly from 98 mL to 59 mL (p<0.05) with the reduction of 49.7%.

Keywords

Urinary tract infections (UTIs); Gatch UP 45-degree positioning; Post-void residual (PVR); Lower urinary tract dysfunction (LUTD); Proper acute care (PAC); Subacute care (SAC)

Introduction

In recent years, medical care for the elderly has been attracting attention in many countries. As the average life expectancy becomes longer, hospitalization of the elderly has been increasing in Japan [1]. Among these, urinary tract infections (UTIs) account for a high proportion, and the medical economic burden has been problem [2]. From large Japanese survey for 5 years, 232 thousand UTI cases were found in 31 million admission data [3]. As a result, incidence was 12.4 per 10000 /year, with death rate 4.5% during admission and 4250 US dollars as median expense. There are about 100,000 cases of pyelonephritis annually that result in hospitalization among elderly people, equating to one in every 100 people aged 90 or older.

Meanwhile, in our hospital, 95 patients were hospitalized with acute pyelonephritis in 2022. Recurrences are common in outpatient care, and may occur even during hospitalization. Therefore, we need to find ways to reduce Urinary tract infections (UTIs). UTIs are known to show the association with lower urinary tract dysfunction (LUTD). Then, urodynamic investigation (UDI) seems to be the gold standard for assessing LUTD [4]. Specific UDI findings are present, such as high detrusor pressures, low bladder capacity and detrusor overactivity that may become greater UTI risk. Post-void residual volume (PVR) means the urine amount retained in the bladder after voluntary void and functions as a diagnostic tool [5]. PVR has been used to evaluate various diseased processes. They include neurogenic bladder, urinary tract infections, urinary outlet obstruction, mechanical obstruction, postoperative urinary retention, medication-induced urinary retention, and so on.

The hospital's motto has been "proper acute care (PAC) and subacute care (SAC)," and we considered whether we could improve it in some way. For many years, the author has been at the bedside of patients, observing minute changes and dealing with UTIs. Based on this experience, we have adopted the positioning on the bed at a 45-degree angle, the middle of standing and lying down. This report provides an overview of current research presentation and some perspectives.

Case Presentation

As history & physicals, the patient is an 88-year-old female. Medical problems included cerebral infarction, type 2 diabetes (T2D), and heart failure (HF), and she had been hospitalized for 3 years. Previously, she had a history of pneumonia and UTI, both of which had improved with antibiotics. At present, she is conscious and has no significant changes in the chest, lungs, heart, or abdomen, and slight paralysis in the left upper and lower limbs.

For several exams, chest X-ray showed no acute changes, and electrocardiogram was within normal limits. Blood test results were TP 6.3 g/dL, Alb 2.1 g/dL, AST (GOT) 15 U/L, ALT (GPT) 10 U/L, BUN 18.4 mg/dL, Cre 0.61 mg/dL, T-Cho 191 mg/dL, LDL-C 117 mg/dL, Glucose 195 mg/dL, HbA1c 6.7 %, Hb 8.7 g/dL, WBC 4700 /μL, CRP 0.46 mg/dL.

Research Method

Regarding the research method, the following schedule was performed.

This is a test to compare two situations, which means usual body position during the first month, and usual + additional position for the second month.
The implementation period is February and March 2024. The protocol will be changed in every month.
As data collection method, conventional catheterization will be conducted for 2 months.

Measurement of PVR volume will be taken twice a week (10:00 a.m.) during regular catheterization.

The body positioning has been changed for left/right aside every 2 hours.

In February, conventional positioning is continued as before.

In March, conventional method plus daily Gatch UP 45-degree for 1 hour twice (0900h, 1500h) is continued every day.

Actual situation of Gatch UP 45-degree position (Figure 1) and a conceptual diagram of the 45-degree up position (Figure 2) are shown.
Data will be collected and analyzed using the t-test, for the changes in self-urination and PVR

Figure 1: Gatch UP 45-degree positioning.

a. Actual situation with 45-degree angle.

b. Schematic diagram of 45-degree angle.

Results

Residual urine volume was measured in this case, which was performed eight times during February and March, and compared. There was no significant difference in spontaneous urination from 339 mL to 323 mL, and residual urine decreased significantly from 98 mL to 59 mL (p<0.05) with the reduction of 49.7% (Figure 2).

Figure 2: Changes in PVR and self-urination for 2 months.

Ethical Considerations

This study was approved by the ethics committee in the hospital. The participants were informed by the document and verbal explanation concerning the study purpose, method, and voluntary participation. They included the situation that there would be no disadvantages for refusal and their personal information would be protected. Written consent was obtained from the participants. In order to make a presentation, written consent was obtained from the family members, with consideration given to protecting the patient's personal information and privacy.

Discussion

This research is to clarify the effect of the Gatch Up 45-degree positioning for the elderly patient with clinical problem of UTI. From obtained data in this study, significantly decreased PVR and stable self-urination urine volume were observed. When the body position becomes Gatch up angle, the patient can take advantage of abdominal muscle pressure to promote spontaneous self-urination, to reduce PVR, and to lead to improved maintenance of lower urinary tract function preventing UTIs [6]. Concerning PVR volume, 883 healthy adults were studied [7]. The data was calculated from adults aged 36-89 years with 59.0 +/- 9.5 years. As a result, 90%/95% percentiles of PVR were 73.2 mL/102.6 mL for men. In contrast, female cases showed 60.5 mL/93.8 mL of PVR, associated with 21%/27% of bladder volume (BV), respectively.

Recently, PVR study was conducted for voiding dysfunction in the acute care hospital [8]. A cross-sectional study was performed for 614 elderly cases. PVR was measured 3 times after admission. Several symptoms of lower urinary tract were obtained by the Core Lower Urinary Tract Symptom Scores (CLSS) [9]. Totally 107 elderly (17.4%) showed the episodes of PVR ≥100 mL. For at least one episode of abnormal PVR, adjusted odds ratio (OR) showed 3.699 for higher age over 75 years and 4.337 for feeling of incomplete emptying. Furthermore, neurological or circulatory diseased states were present for two or three episodes.

A study was conducted for the relationship of PVR and lower urinary tract symptoms (LUTS) [10]. The patients (n=939) were recruited with 183 females. Among them, positive correlation was shown between incomplete bladder emptying sensation and PVR volume in all ages of female (p=0.0001). For female group, voiding and storage symptoms did not show correlation with higher PVR volume. From mentioned above, all females who complain of incomplete emptying feeling should undergone PVR examination in the future.

Females tend to have more experiences of UTIs. UTI symptoms were studied for 55 thousand cases of clean intermittent catheter (CIC) users. As a result, four main prevalent urinary problems showed urinary incontinence (34%), urinary retention (34%), residual urine (32%), and overactive bladder (32%) [11]. When compared with those of males, females showed higher risk of UTIs with relative risk ratio of 1.43. The large survey on UTI has been observed in Japan. Among admitted elderly cases with UTI, in-hospital mortality rate was 4.5%. Related risk factors for poor survival results have included older age, male sex, non-academic hospital, lower bed capacity, winter admission, low body mass index, ambulance use, coma status, sepsis heart failure, renal failure, pneumonia, cerebrovascular diseases, use of antihypoglycemic agents (OHAs) [12]. Consequently, UTI should be managed and protected properly for refraining from exacerbation.

Concerning female cases of frequent urinary tract infections (UTIs), lower urinary tract dysfunction (LUTD) was studied for 100 consecutive cases with 64.0 years in average [13]. The results showed that voiding and storage dysfunctions 90%, bladder dysfunctional voiding 25%, poor relaxation of the pelvic floor muscle 20%, neck dysfunction 19%, detrusor underactivity 10%, and so on. Among female cases of LUTS, moderate ratio of bladder outlet obstruction (BOO) can be found. BOO has been diagnosed as the maximum flow rate (Qmax) is less than 12mL/s and the detrusor pressure at maximum flow rate (Pdet.Qmax) is more than 20cmH₂O [14]. In comparison with female cases without BOO, cases with BOO showed increased incidence to urgent urination, frequent urination, insufficient urination, nocturia and dysuria.

In summary, novel trial of Gatch UP 45-degree positioning is described, which would be for decreasing post-void residual (PVR) urine volume. It is just proposed moment, then it will be continued to develop the research. Clinical problem of frequent UTIs in the elderly is hopefully improved or decreased in the future.

Conflict of interest: The author declares no conflict of interest.

Funding: There was no funding received for this paper.

International Journal of Case Reports and Clinical Images