Stesura Seveso Archivio Italiano di Urologia e Andrologia 2024; 96(2):1294 1 ORIGINAL PAPER Transabdominal ultrasound (US) as a preferred non-inva- sive radiological imaging method for evaluating the uri- nary system. Transabdominal ultrasound (US) as a pre- ferred non-invasive radiological imaging method for eval- uating the urinary system. Limitations of transabdominal US in providing detailed information about bladder dynamics are acknowledged, especially concerning the morphology of bladder neck, which can vary based on factors such as body position and urine volume. Recent studies on ultrasonographic examination of bladder neck dynamics in women highlight the importance of under- standing these dynamics (3, 4). The specific aspects eval- uated in these studies, such as mucosal thickness, mor- phology of trigonum and bladder floor, and anteroposte- rior angle of the bladder wall, demonstrate the complex- ity of assessing bladder function (3-6). This suggests a focus on understanding how the bladder neck behaves in patients with OAB compared to those without this condi- tion METHODS Before study initiation, approval was obtained from the ethics committee of Tepecik Education and Research Hospital (Approval number: 2023/08-31), and consent forms from the patients who agreed to participate in the study were obtained. The study was conducted in accor- dance with the principles of the Declaration of Helsinki. Patients with kidney disease, stone disease, a history of urinary system interventions, active urinary tract infec- tions, a history of multiple drug use, and anomalies detected in urinary system by ultrasound were excluded from the study. This prospective study was conducted between October 2023 and December 2023. Among the patients who vis- ited our clinic due to urinary symptoms between the mentioned dates, 29 female patients diagnosed with Overactive Bladder (OAB) were planned to be included in the study group (Group I). Additionally, 30 female patients who did not exhibit urinary symptoms were planned to be included in the control group (Group II). Ultrasonographic examination The patients were assessed in the supine position, as it provides the most stable bladder conditions during the examination. Following a period for allowing patients to Aim: The aim of this study was to compare the differences between angles of bladder neck in girls with overactive bladder and those in healthy ones using transabdominal ultrasonography. Materials and Methods: This study consists of 28 girls compli- cated with overactive bladder (Group I) and 40 healthy girls (Group II). The anteroposterior vesical wall angle (APVA), ure- throposterior vesical wall angle (UPVA), urethroanterior vesical wall angle (UAVA), thickness of bladder mucosa, distance of urethral orifices, and distance between ureter and urethra ori- fice were measured in supine position using transabdominal ultrasonography. The results were compared between the two groups. Results: UAVA in Group I was higher than Group II (135.2 ± 12.2 mm vs. 117.4 ± 14.0 mm; p = 0.009). UPVA was smaller in Group I than Group II (114.6 ± 19.5 mm vs. 135.3 ± 16.5 mm; p = 0.014). The distance between the ureteral orifices was 31.8 ± 8.5 mm in Group I and 17.0 ± 4.1 mm in Group II (p < 0.001). There was no statistically significant difference between groups in terms of APVA, bladder mucosa thickness, and dis- tance between ureter and urethra orifice (p > 0.05). Conclusion: Bladder neck dynamics may play an important role in overactive bladder pathophysiology due to differences in UPVA, UAV, and location of ureteral orifices in this patient pop- ulation. KEY WORDS: Overactive bladder; Ultrasonography; Bladder. Submitted 18 January 2024; Accepted 15 February 2024 INTRODUCTION Overactive bladder (OAB) is a dysmotility disorder charac- terized by various symptoms, including a sudden urge to urinate, urinary incontinence, and frequent urinary tract infections. It is associated with the overstimulation of the detrusor muscle during the bladder's filling phase. In some cases, individuals, especially women, may contract pelvic floor muscles voluntarily by squatting and apply- ing pressure to the urethra with their heels to prevent uri- nary incontinence (1). While factors such as age, chronic neurological diseases, diabetes, and spinal injuries can contribute to OAB in adults, the etiology of this disorder in women is not fully understood. Diagnosing OAB in women involves a comprehensive approach, including lower urinary tract ultrasonography (US), urodynamic examination, and a detailed patient history (2). Differences in bladder neck angles between female patients with overactive bladders and healthy peers Mehmet Yoldas, Mehmet Zeynel Keskin 1 Tepecik Training and Research Hospital Urology Clinic, Izmir, Turkey. DOI: 10.4081/aiua.2024.12294 Summary Archivio Italiano di Urologia e Andrologia 2024; 96(2):1294 M. Yoldas, M. Zeynel Keskin 2 achieve bladder fullness, the examination was conducted by scanning the suprapubic abdominal wall in both sagit- tal and transverse planes. Initially, the three-dimensional measurement of urine in the bladder was performed, fol- lowed by the calculation of bladder volume Firstly, we assessed bladder volume, bladder wall thick- ness, the presence of trabeculation, and any additional pathology. Subsequently, we examined the localization of both kidneys, their contours, and the structure of the pelvicalyceal system. Following that, we measured kidney sizes and parenchymal thicknesses. The mucosal thick- ness of the bladder wall was measured within a distance of up to 2 cm from the bladder neck, while the distance between the bladder smooth muscle layer and the mucos- al surface was measured to include the mucosal-submu- cosal low-echo area. The diameters of both ureteral ori- fices were then measured at the axial plane. Additionally, we determined whether the ureteral orifices opened to the bladder in the normal position. The bladder neck was easily visualized as a 'V' depression in the sagittal plane, and the urethrovesical junction was identified. A line parallel to the urethra was drawn throughout the urethra from the level of the urethrovesi- cal junction. The anteroposterior vesical wall angle (APVA), urethroposterior vesical wall angle (UPVA), and urethroanterior vesical wall angle (UAVA) were measured. The APVA of the bladder neck was calculated by meas- uring the angle between the anterior wall (anterior base plate) and the posterior wall in the sagittal plane. The UPVA between the urethra and the posterior vesical wall and the UAVA between the urethra and anterior wall were then measured. Subsequently, the distance between the ureteral orifices and between the ureteral and ure- thral orifices was measured on the axial plane. Measurement is shown in Figure 1. Statistical analysis All data were analyzed using PASW version 18.0 (SPSS Inc., Chicago, IL, USA). Descriptive data were expressed as mean ± SD. Differences between the two groups were assessed using the Mann-Whitney U test for categorized variables and Student’s t-test for continuous variables. A p-value of < 0.05 was considered statistically significant. RESULTS The age range of the patients was 25 to 49 years, with no difference in age and weight observed between the two groups (Table 1). UAVA was higher in Group I than in Group II (138.4° ± 11.2° vs. 115.2° ± 13.4°, respectively; p = 0.008), whereas UPVA was lower in Group I than in Group II (118.1° ± 18.5° vs. 138.2° ± 17.7°, respectively; p = 0.012). The mean distance between the ureteral ori- fices was 41.7 ± 7.5 mm in Group I and 25.0 ± 3.2 mm in Group II (p = 0.000). No significant difference in the results of other measurements for the lower urinary sys- tem was observed between the two groups (p > 0.05; Table 1). Figure 1. Measurement of anteroposterior vesical wall angle (APVA), urethroposterior vesical wall angle (UPVA), and urethroanterior vesical wall angle (UAVA). Archivio Italiano di Urologia e Andrologia 2024; 96(2):1294 3 Differences in bladder neck angles DISCUSSION The current study revealed that patients with Overactive Bladder (OAB) exhibited decreased UPVA values, increased UAVA values, and an increased distance between orifices. A prior study, albeit with a limited num- ber of adult patients, identified bladder neck changes associated with post-hormonal alterations in bladder neck fibroblast activity (5). Considering that our participants were female patients in the hormonally active period, we support the validity of this hypothesis for the OAB patient group in our study. We propose that the variances in UPVA and UAVA of the bladder neck among OAB patients may be linked to changes in the bladder wall attributed to excessive detru- sor activity. Sugaya et al., who determined Anteroposterior Vesical Wall Angle (APVA) values in healthy individuals aged 0-29 years (6), found that children under 10 years old had lower APVA values. Those over 10 years old, however, exhibited values similar to adults that were associated with hormonal changes. However, at present, no study has comprehensively investigated bladder neck angles during adulthood. Lower urinary tract disorders are prevalent in childhood, with anatomical issues, neurological impairments, and behavioral disorders in toilet training identified as etiologi- cal factors (7). Additionally, Goessaert et al. demonstrated that children experiencing daytime urinary incontinence had a twofold increased risk of sudden feelings of urination and urinary incontinence in adulthood. Furthermore, Song et al. (8) found that individuals with complaints of consti- pation and urinary incontinence in adulthood had similar issues during childhood. These studies suggest a potential pathological link between childhood and adult disorders. If symptoms persist from childhood to adulthood, as suggest- ed by the aforementioned studies, it becomes crucial to understand the pathophysiology of the disease during childhood and implement appropriate treatment, prioritiz- ing the lifelong well-being of the patient The strength of our study lies in being the first to explore bladder neck angles in women, confirming that women diagnosed with OAB exhibit alterations in bladder neck angles. However, a notable limitation of the current study is the relatively small number of cases and our exclusive focus on women. CONCLUSIONS Despite the link between OAB in childhood and similar urinary symptoms in adulthood, the pathophysiology of this relationship has not been fully elucidated. We posit that a more detailed investigation of the bladder neck and its dynamics could yield significant insights not only for the diagnosis and treatment of the disorder during child- hood but also for addressing similar symptoms in adult- hood. Our findings, indicating changes in bladder neck angles among women diagnosed with OAB, suggest a potential role of these changes in the pathophysiology of OAB in girls. Additionally, the measurement of bladder neck angles could serve as a diagnostic tool for OAB. Therefore, further large-scale studies are needed to uncov- er different approaches for the treatment of this disease. REFERENCES 1. Drake MJ. Fundamentals of terminology in lower urinary tract function. Neurourol Urodyn 2018; 37:13-19. 2. Chen LC, Kuo HC. Pathophysiology of refractory overactive blad- der. Lower urinary tract symptoms 2019; 11:177-181. 3. Sugaya K, Nishijima S, Oda M, et al. Transabdominal vesical sonography of urethral syndrome and stress incontinence. Int J Urol; 2003: 10:36-42. 4. Tafuro L, Montaldo P, Iervolino LR, et al. Ultrasonographic bladder measurements can replace urodynamic study for the diagnosis of non- monosymptomatic nocturnal enuresis. BJU Int. 2010; 105:108-111. 5. Lo TS, Ng KL, Hsieh WC, et al. Ultrasonography and clinical out- comes following anti-incontinence procedures (Solyx™ tape): a 3- year post-operative review. Int Urogynecol J. 2022; 33:2749-2759. 6. Sugaya K, Nishijima S, Oda M, et al. Ultrasonographic changes of the female bladder neck during development. Int J Urol. 2002; 9:668- 671. 7. Fotter R, Riccabona M. Functional disorders of the lower urinary tract in children. Radiologe. 2005; 45:1085-1091. 8. Goessaert AS, Schoenaers B, Opdenakker O, et al. Long-term fol- lowup of children with nocturnal enuresis: increased frequency of nocturia in adulthood. J Urol. 2014; 191:1866-1870. 9. Song QX, Wang L, Cheng X, et al. The clinical features and pre- dictive factors of nocturnal enuresis in adult men. BJU Int. 2020; 126:472-480. Table 1. Comparison of demographic and study results between both groups. Parameter Study group 1 Control group 2 P (n = 29) (n = 30) Age (year) 37.4 ± 2.5 38.1 ± 1.9 0.401 Weight (kg) 66.0 ± 9.2 68.2 ± 10.1 0.509 Anterior-posterior vesical angle 126.5 ± 15.7 113.4 ± 15.4 0.079 Urethro-anterior vesical angle 138.4 ± 11.2 115.2 ± 13.4 0.008 Urethro-posterior vesical angle 118.1 ± 18.5 138.2 ± 17.7 0.012 Bladder volume (mm3) 59.2 ± 24.1 61.5 ± 41.3 0.845 Mucosa thickness in bladder neck (mm) 1.9 ± 0.7 1.6 ± 0.6 0.327 Length of urethra (mm) 43.9 ± 8.7 39.1 ± 8.7 0.656 Ureteral–urethral orifice distance (mm) 29.2 ± 8.7 28.9 ± 7.9 0.994 Distance between the ureteral orifices (mm) 41.7 ± 7.5 25.0 ± 3.2 0.000 Data were expressed in mean ± SD (standard deviation). Correspondence Mehmet Yoldas, MD (Corresponding Author) yoldas_2297@hotmail.com Mehmet Zeynel Keskin, MD zeynel_akd@hotmail.com Republic of Turkey Ministry of Health Izmir Provincial Health Directorate Izmir University of Health Sciences Tepecik Training and Research Hospital Urology Clinic, Izmir, Turkey; Yenişehir, Gaziler Cd No:468, 35020 Konak/Izmir Conflict of interest: The authors declare no potential conflict of interest.