Neurourology and Urodynamics 32:1014–1018 (2013)

Age- and Gender-Specific Nomograms For Single and

Dual Post-Void Residual Urine In Healthy Children
Shang-Jen Chang,1,2 I-Ni Chiang,3,4 Cheng-Hsing Hsieh,1,2 Chia-Da Lin,1,2 and
Stephen Shei-Dei Yang1,2*
1
Division of Urology, Buddhist Tzu Chi General Hospital, Taipei Branch, New Taipei, Taiwan
2
Medical College of Buddhist, Tzu Chi University, Hualien, Taiwan
3
Division of Urology, Department of Surgery, Keelung Hospital, Keelung, Taiwan
4
Department of Urology, National Taiwan University Hospital, Taipei, Taiwan

Purpose: To establish the first age- and gender-specific nomograms for single and two consecutive tests for post-void
residual urine (PVR). Material and Methods: Healthy children aged 4–12 years were enrolled for two sets of uroflow-
metry and PVR. The first PVR and the lower value of the two consecutive PVRs of each child with a voided volume

50 ml were included for construction of Single- and Dual-PVR nomograms. Children with possible urinary tract infec-
tion or lower urinary tract dysfunctions were excluded. Results and Limitations: Totally, 1,128 children (583 boys
and 545 girls) with a mean age of 7.7  2.2 years were eligible for analysis. The 95th percentile of Single-PVR for all
children was 27.2 ml, or 19.2% of bladder capacity (BC), while that for Dual-PVR were 11.2 ml or 6.0% of BC, respec-
tively. Multivariate studies showed that PVR was positively associated with BC, negatively associated with age, higher
in boys than girls, and higher in abnormal uroflow patterns. For children aged 6 years, a single PVR >30 ml or >21%
BC, or repetitive PVR >20 ml or >10% BC can be regarded as elevated. For children aged
7 years, a single PVR
>20 ml or 15% BC, or repetitive PVR >10 ml or 6% BC can be redefined as elevated. Conclusions: Age, gender, and
BC should be taken into considerations at interpretation of PVR tests in children. Repeating PVR test is recommended
when a single PVR is higher than the 95th percentile of age- and gender-specific PVR. Neurourol. Urodynam. 32:1014–
1018, 2013. ß 2013 Wiley Periodicals, Inc.

Key words: children; lower urinary tract dysfunction; nomogram; post-void residual urine; urinary tract infection

INTRODUCTION PATIENTS AND METHODS

Post-void residual urine volume (PVR) has long been
regarded as a significant risk factor for the occurrence and re-
currence of urinary tract infections (UTI).1,2 Clinically, it was
routinely used as an important indicator of bladder emptying
function and also a non-negligible factor to follow up on the
children’s responses to the treatments.3–6 Despite the clinical
importance of PVR, there are no existing nomograms for PVR.
Ratio of residual urine is classically expressed as PVR divided
by (voided volume þPVR), which bears the concept of bladder
emptying efficiency. Some experts considered the effects of
age on PVR, and then arbitrarily defined PVR >10% expected
bladder capacity (EBC) as elevated PVR which failed to delin-
eate its association with UTI or dysfunctional voiding.1,2,7 In
2006, the International Children Continence Society’s (ICCS)
clearly cited that definition of PVR >10% of bladder capacity
(BC) as abnormal, often stated in adults, is not relevant in chil-
dren.4 Based on experts’ consensus, rather than on solid evi-
dence, ICCS suggested that PVR of 5 and 20 ml as insufficient
and incomplete bladder emptying in which PVR examination
should be repeated and that abnormal or incomplete bladder
emptying is defined as repetitive PVR >20 ml.4 Children are
expected to empty the bladder more completely as children
grow up with ages.8 PVR was also dependent on BC.7,9 Age
and BC-specific nomograms are desperately indicated for clini-
cal practice. Besides, great variations of PVR between two con-
secutive voids were observed in children.9,10 Hence, we
conducted this large-scale cross-sectional study to establish
the first nomograms for single and two consecutive tests of
PVR in children with incorporation of age and BC, and to ex-
amine the ICCS’ definition on PVR.
The study was approved by the Institutional Review Board
at our Hospital and signed informed consents were obtained
before enrollment. From September 2006 through February
2011, all the kindergartens and elementary schools in Xing-
Dian City were invited to join the study. Finally, 14 kinder-
gartens and five elementary schools were randomly selected
and agreed for enrollment. For each elementary school, we
further randomly selected classes from each grade of each ele-
mentary school with an intention to invite 100 boys and 100
girls per age group. As for kindergartens, all the children in
the selected kindergartens were invited. Children with con-
genital genitourinary tract anomaly, neurological anomaly, or
history of UTI were excluded from analysis. Children with UTI
or asymptomatic bacteriuria, that is, positive leukocyte ester-
ase or nitrite on urinary dipsticks tests, were further excluded.
An uroflowmeter (UFM Master1, MMS, Netherlands) was set
up in the toilets of each kindergarten or elementary school.
The children were requested to do two sets of uroflowmetry
Conflict of interest: none.
Roger Dmochowski led the peer-review process as the Associate Editor responsi-
ble for the paper.
Grant sponsor: Buddhist Tzu Chi General Hospital, Taipei Branch; Grant number:
TCRD-TPE-97-C2-1; IRB; Grant number: 97-IRB-026-coP.
*Correspondence to: Stephen Shei-Dei Yang, #289, Chienkuo Road, 16F, Division of
Urology, Buddhist Tzu Chi General Hospital, Taipei Branch, Xindian, New Taipei
231, Taiwan. E-mail: krissygnet@yahoo.com.tw
Received 19 July 2012; Accepted 27 September 2012
Published online 17 April 2013 in Wiley Online Library
(wileyonlinelibrary.com).
DOI 10.1002/nau.22342

ß 2013 Wiley Periodicals, Inc.


and PVR. The study nurse helped them finish the test. The
boys voided in a standing position and the girls in a sitting
position with adequate foot support. All PVRs were assessed
within 5 min after voiding with suprapubic ultrasound (Logiq
Book1, GE Medical Systems, Milwaukee, WI), and estimated
by the equation of height  width  depth  0.52 ml11 only
when VV was
50 ml. BC is defined as ‘‘voided volume
(VV) þ PVR,’’ and expressed as percent of the EBC, that is
(age þ 1)  30 ml.4
After independent interpretations of uroflowmetry by two
pediatric urologists,12 children with repetitive abnormal flow
patterns suspected of having voiding dysfunction were ex-
cluded. Uroflow patterns were grouped as normal bell-shaped
and abnormal patterns including all the nonbell-shaped pat-
terns.12 The first set of uroflowmetry curve and PVR of each
child with a VV
50 ml was included for analysis and con-
struction of Single-PVR nomograms. The lower values of two
consecutive PVRs on the same day of the same child with a
VV
50 ml were included for construction of Dual-PVR
nomograms.
Statistical Analysis
Data was expressed as mean  standard deviation except
that PVR was expressed as median value. Data was analyzed
by commercial statistical software (Medcalc1, version 12.3,
Mariakerke, Belgium). Demographic and voiding parameters
were compared via an independent t test (continuous demo-
graphic variables), Mann–Whitney U tests (ordinal data) and
Chi-square test (nominal data). The distribution of PVRs in
children was positively skewed, therefore, the nomograms
were plotted descriptively with percentile statistics with sta-
tistical software (R1, version 2.13.1.). Multivariate analysis
was used to observe the factors affecting PVR. A P-value of
<0.05 was considered statistically significant.
RESULTS
Data Collections
Among 1,980 invited children, 1,410 children/parents
agreed to join the study. After excluding children with uro-
flowmetry of voided volume <50 ml (n ¼ 218), artifacts
(n ¼ 4), or children suspected of having UTI (n ¼ 16) or repeti-
tive abnormal flow patterns (n ¼ 44), 1,128 children (563 boys
and 528 girls) with a mean age of 7.7  2.2 years were en-
rolled for analysis. Table I lists the characteristics of studied
subjects.
Uroflow Patterns and PVR
Of the 1,128 first uroflowmetry curves, 960 (85.1%) were
classified as normal bell-shaped and 168 (14.9%) as abnormal
nonbell-shaped. Abnormal flow patterns were associated with
higher PVR (10.6 ml vs. 6.1 ml, P < 0.01) and higher PVR/BC
Nomograms for PVR 1015
(5.2% vs. 3.9%, P ¼ 0.02) than those of normal flow curves. The
BC in cases with abnormal flow curves were higher than those
with normal flow curves (85.7% vs. 65.7% of EBC, P < 0.01).
Single-PVR Nomograms
The 50th, 75th, 90th, and 95th percentiles of Single-PVR for
all children were 2.7, 6.7, 16.2, and 27.2 ml, respectively. The
50th, 75th, 90th, and 95th percentiles of PVR in percent of BC
for all children were 2.1%, 5.1%, 11.7%, and 19.2%, respectively.
Multivariate analysis revealed that single PVR value was sig-
nificantly affected by age (P < 0.01), abnormal flow patterns
(bell-shaped vs. nonbell-shaped, P ¼ 0.01), BC (P < 0.01), and
gender (P ¼ 0.01). Boys had higher PVR than girls. Table II lists
the age-specific percentile of Single-PVRs in ml and percent of
BC.
Dual-PVR Nomograms
Of the 1,128 children 888 (78.7%) had two uroflowmetry
curves with voided volumes
50 ml. The lower value of the
two consecutive PVRs from each child was used for construc-
tion of Dual-PVR nomograms. Figure 1 depicts that Dual-PVR
positively correlated with BC and negatively correlated with
age. The 90th and 95th percentiles of Dual-PVR for all children
were 7.6 ml and 4.9% of BC, and 11.2 ml and 6.0% of BC, re-
spectively. Table III list the age- and gender-specific nomo-
grams for PVR in boys and girls. Boys had a higher PVR than
girls in all age groups.
DISCUSSION
To our knowledge, this is the first and largest study enroll-
ing more than one thousand healthy children to construct
nomograms for single and two consecutive tests for PVR. The
current nomograms can serve as a clinical guidance for pedia-
tricians and pediatric urologists to predict the occurrence and
recurrence of UTI, and to evaluate and monitor treatment
responses of lower urinary tract dysfunctions in children. For
clinical practice, elevated PVR can be redefined as single PVR

30 ml or
21% of BC in children aged  6 years; or
20 ml
or
15% of BC in children aged
7 years (Table II). Elevated
PVR can be better defined as the lower value of two consecu-
tive PVRs
20 ml or
10% BC in children aged 6 years; or

10 ml or
6% BC in children aged
7 years. Since great var-
iations of PVR existed between voids,9,10 we recommend sec-
ond PVR test in cases with a first PVR above the 95th
percentile of age- and gender-specific Dual-PVR nomograms
(Table III).
In the multivariate analysis, PVR was significantly affected
by BC, age, genders, and uroflow patterns. BC should be taken
into consideration when constructing the normalcy of PVR, as
TABLE II. Age-Specific Percentile of Single-PVR

Age 4–6 years 7–9 years 10–12 years

TABLE I. Baseline Characteristics and Uroflow Parameters of Enrolled groups (n ¼ 387) (n ¼ 478) (n ¼ 263)
Children

Percentile ml % BC ml % BC ml % BC
All (n ¼ 1128) Boy (n ¼ 583) Girl (n ¼ 545) P-value

50th 2.7 2.4 1.7 1.7 2.4 1.8

Age (years) 7.7  2.2 7.8  2.2 7.6  2.2 0.09
75th 9.2 6.7 4.2 3.6 5.2 4.2
Qmax (ml/sec) 20.1  7.4 19.3  6.8 21.0  7.9 <0.01
90th 20.1 13.7 12.1 8.5 11.9 9.0
VV (ml) 169.2  98.5 160.3  92.8 178.7  103.8 <0.01
95th 29.9 21.0 22.2 14.6 18.9 12.5
PVR (ml) 7.4  11.9 7.8  12.7 6.8  11.0 0.10
PVR/BC 0.04  0.06 0.05  0.06 0.04  0.06 0.11
BC ¼ bladder capacity ¼ voided volume þ PVR.

Neurourology and Urodynamics DOI 10.1002/nau

1016 Chang et al.
TABLE III. Age-Specific Nomograms for Dual-PVR in Boys and Girls

Age groups/Percentile 4–6 years 7–9 years 10–12 years

Boys (n ¼ 138) Girls (n ¼ 147) Boys (n ¼ 199) Girls (n ¼ 187) Boys (n ¼ 115) Girls (n ¼ 102)

PVR ml % BC ml % BC ml % BC ml % BC ml % BC ml % BC

50th 1.9 1.7 1.6 1.3 1.6 1.1 1.1 0.7 1.9 1.2 1.7 0.8
75th 6.3 4.0 4.3 3.1 2.8 2.3 2.4 1.8 4.7 2.4 3.3 2.3
90th 13.8 10.5 11.1 6.5 6.3 4.3 4.7 2.7 10.2 4.5 8.8 4.8
95th 18.9 15.6 16.2 9.7 9.2 7.3 7.2 3.8 12.6 6.3 11.5 5.6

BC ¼ bladder capacity ¼ voided volume þ PVR.

the PVR was dependent on voided volume13 or BC.7,9 We con-
firmed again that PVR was significantly increased as the BC
increased (Fig. 1). Up to date, there is no recommendation for
the lower limit of BC as relevant for interpretation of PVR.
ICCS recommended that uroflowmetry with a voided volume
<50 ml was not relevant for interpretation of voiding func-
tion,14 therefore, those data with a VV <50 ml were excluded
from the analysis. Based on our observation, bladder empty-
ing was effective at a BC of 40% EBC (Fig. 1). Recently, Hoebeke
et al.15 and Yang et al.16 suggested a BC
50% of EBC as
relevant for interpretation of uroflow patterns in children.
However, Bartkowski set a BC no less than two thirds of EBC
as a requirement of successful non-invasive urodynamic tests.
Further studies are required to define the lower limit of BC for
adequate bladder emptying.
An age- and gender-specific percentile of Dual-PVR in millili-
ter and percent of BC will be more useful for clinical reference.
Our results concurred with the reports from Jansson et al.8
that PVR decreased with age (Tables II and III). However, this
trend of improvement in bladder emptying was less significant

Fig. 1. Dual PVR Nomograms for PVR in milliliter (A,B) and PVR in percent of BC (C,D) over varied age and BC/EBC.
The lines of 50th, 75th, 90th, and 95th percentiles were plotted separately in the nomograms.

Neurourology and Urodynamics DOI 10.1002/nau


after the age of 7 years (Fig. 1). The improvement of bladder
emptying with increasing age could be attributed to the devel-
opmental growth of children. Our results were in line with
Gierup17 that girls had higher peak flow rate than boys
(Table I). We further demonstrated that boys had a higher PVR
than girls after adjustment of age and BC. The anatomic differ-
ence may explain the gender difference in PVR and uroflow-
metry parameters.
Abnormal flow patterns were associated with larger BC and
higher PVR. Similarly, Gierup17 and Bartkowski and Dou-
brava7 found that abnormal uroflowmetry curves occurred in
children with higher voided volumes. Chang and Yang9 fur-
ther demonstrated that abnormal flow patterns and elevated
PVR were frequently observed in a BC
115% EBC or voided
volume
100% EBC.13 Though the prevalence of any abnormal
uroflow patterns in healthy children was around 15% in this
and other studies,18–20 repetitive abnormal flow patterns was
observed only in 4.7% (44/932) of the studied children. To
avoid the interference by the children with potential lower
urinary tract dysfunction, those PVRs with repetitive abnor-
mal flow patterns were excluded from the current nomograms
for PVR.
The ranges of single PVR tests were quite wide in all age
groups. The value of 95th percentile of single PVR was
much greater than the lower value of repetitive PVR
(Tables II and III). ICCS regarding PVR >5 and >20 ml as
insufficient and abnormal emptying may be applied to
children aged 7–12 years, whose 75th and 95th percentile
of Single-PVR were around 5 and 20 ml, respectively. The
variability of PVRs between voids was great in children.9,10
Therefore, repetitive measurements of PVR were recom-
mended by ICCS when PVR was more than 5 ml.4 From our
results, the lower value of two consecutive PVR tests was
generally <20 ml or 10% BC, and 10 ml or 6% of BC in chil-
dren with age 6 years and
7 years, respectively. There-
fore, we recommend repeating PVR test when the first PVR
value is above the aforementioned age- and gender-specific
values. Nomogram for Single-PVR will be useful in un-co-
operative children or busy clinic. While the nomogram for
Dual-PVR provides a reliable observation on bladder empty-
ing function. In the future, the application of Dual-PVR
may avoid unnecessary invasive urodynamic tests and
serve as a better indicator in the diagnosis and follow-up
of pediatric lower urinary tract dysfunction.
It is hypothesized that the main defense mechanism of uri-
nary bladder against infections is bladder emptying. Children
with higher PVR are associated with higher probability of de-
veloping and recurring UTI.1,2 Previous observations on the re-
lationship between PVR and UTI bear the following bias:
single PVR measurements, inadequate definition of elevated
PVR as >10% EBC, wide range of age in the enrolled children
who were mostly girls.2,7 Because PVR is positively associated
with BC and negatively associated with age, a PVR of >10%
EBC as pathologically high may not be applied to children of
different age groups. For example, the 10% EBC in children of
age 4 and 12 years were 15 and 39 ml, respectively. A single
PVR of 15 ml is around 80th percentile of children aged 4 years
and was misinterpreted as abnormal. However, a single PVR
of 39 ml is far beyond 95th percentile of children aged
12 years, and some elevated PVR may be misinterpreted as
normal. As such, the cut-off value of PVR predicting recurrent
UTI could not be established yet.2 PVR is significantly affected
by BC, age, gender, and number of void. The current Single-
and Dual-PVR nomograms provide a new definition of elevat-
ed PVR, with incorporation of all the four factors affecting
PVR. These nomograms may help future studies to elucidate
Neurourology and Urodynamics DOI 10.1002/nau
Nomograms for PVR 1017
the relationship between PVR and the occurrence, or recur-
rence of UTI.
The limitation of the current study is that whether one
can extrapolate the current results and conclusions to the
global pediatric population need further studies because
the current study was a cross-sectional, randomly selected
study in one geographical location, measuring essentially
one ethnic population (Chinese). Lastly, it is very difficult
to define ‘‘normal’’ and ‘‘healthy’’ children as there is great
variation in children of normal populations. Therefore, a
large number of children were enrolled for constructing
the nomogram. Although children with repeated abnormal
flow patterns and suspected of having UTIs were excluded
we did not exclude those with constipation which is a very
import factor that may impair the bladder function, and
was associated with higher rates of incomplete bladder
emptying.21 Since the nomograms were presented in per-
centile, further studies could use the nomograms to see
whether constipated children have higher percentiles of
PVR in ml or percent of BC and whether these children
have improved bladder emptying after treatment of
constipation.
CONCLUSION
Age- and gender-specific nomograms for PVR are con-
structed for clinical practice. Repetitive PVR
20 ml or
10%
BC could be defined as elevated in children aged
6 years. Re-
petitive PVR
10 ml or 6% BC could be defined as elevated
in children aged
7 years. The aforementioned values are a
little higher in boys, and lower in girls. Further works on vali-
dation and clinical applications of the PVR nomograms are
warranted.
REFERENCES
1. Nelson JD, Cooper CS, Boyt MA, et al. Improved uroflow parameters and
post-void residual following biofeedback therapy in pediatric patients with
dysfunctional voiding does not correspond to outcome. J Urol 2004;172:
1653–6.
2. Shaikh N, Abedin S, Docimo SG. Can ultrasonography or uroflowmetry pre-
dict which children with voiding dysfunction will have recurrent urinary
tract infections? J Urol 2005;174:1620–2.
3. Vanderbrink BA, Gitlin J, Toro S, et al. Effect of tamsulosin on systemic blood
pressure and nonneurogenic dysfunctional voiding in children. J Urol
2009;181:817–22.
4. Neveus T, von GA, Hoebeke P, et al. The standardization of terminology of
lower urinary tract function in children and adolescents: Report from the
Standardisation Committee of the International Children’s Continence Soci-
ety. J Urol 2006;176:314–24.
5. Youssif M, Dawood W, Shabaan S, et al. Early valve ablation can decrease
the incidence of bladder dysfunction in boys with posterior urethral valves.
J Urol 2009;182:1765–8.
6. Yang SS, Wang CC. Outpatient biofeedback relaxation of the pelvic floor in
treating pediatric dysfunctional voiding: A short-course program is effec-
tive. Urol Int 2005;74:118–22.
7. Bartkowski DP, Doubrava RG. Ability of a normal dysfunctional voiding
symptom score to predict uroflowmetry and external urinary sphincter elec-
tromyography patterns in children. J Urol 2004;172:1980–5.
8. Jansson UB, Hanson M, Sillen U, et al. Voiding pattern and acquisition of
bladder control from birth to age 6 years—A longitudinal study. J Urol 2005;
174:289–93.
9. Chang SJ, Yang SS. Variability, related factors and normal reference value of
post-void residual urine in healthy kindergarteners. J Urol 2009;182:1933–8.
10. Flores MF, Bolong D. A prospective study on the consistency and reproduc-
ibility of uroflowmetry studies and post void residual measurements at a
bladder volume of 50–100% estimated bladder capacity in children. J Urol
2012;4:e589.
11. Erasmie U, Lidefelt KJ. Accuracy of ultrasonic assessment of residual urine
in children. Pediatr Radiol 1989;19:388–90.
12. Chang SJ, Yang SS. Inter-observer and intra-observer agreement on interpre-
tation of uroflowmetry curves of kindergarten children. J Pediatr Urol 2008;
4:422–7.
1018 Chang et al.
13. Chang SJ, Yang SS, Chiang IN. Large voided volume suggestive of abnormal
uroflow pattern and elevated post-void residual urine. Neurourol Urodyn
2011;30:58–61.
14. Norgaard JP, van Gool JD, Hjalmas K, et al. Standardization and definitions
in lower urinary tract dysfunction in children. International Children’s Con-
tinence Society. Br J Urol 1998;81:1–16.
15. Hoebeke P, Bower W, Combs A, et al. Diagnostic evaluation of children with
daytime incontinence. J Urol 2010;183:699–703.
16. Yang SS, Wang CC, Chen YT. Home uroflowmetry for the evaluation of boys
with urinary incontinence. J Urol 2003;169:1505–7.
Neurourology and Urodynamics DOI 10.1002/nau
17. Gierup J. Micturition studies in infants and children. Normal urinary flow.
Scand J Urol Nephrol 1970;4:191–7.
18. Mattsson S, Spangberg A. Flow rate nomograms in 7- to 16-year-old healthy
children. Neurourol Urodyn 1994;13:267–80.
19. Bower WF, Kwok B, Yeung CK. Variability in normative urine flow rates. J
Urol 2004;171:2657–9.
20. Gutierrez SC. Urine flow in childhood: A study of flow chart parameters
based on 1,361 uroflowmetry tests. J Urol 1997;157:1426–8.
21. Chang SJ, Hsieh CH, Yang SS. Constipation is associated with incomplete
bladder emptying in healthy children. Neurourol Urodyn 2012;31:105–8.