Urodynamics is widely used to evaluate lower urinary tract disorders such as urinary incontinence, voiding dysfunction, and neurogenic bladder. Because this differential diagnostic tool includes placement of catheters in the urethra, rectum, or vagina to measure bladder function and capacity, and in some cases, the placement of a concentric needle electrode in the external urethral sphincter for electromyography, examining intravesical, detrusor, and urethral pressures as the bladder is filled with saline. It is recognized as an invasive diagnostic tool [1,2].

It is used to identify contributing factors to lower urinary tract dysfunction, to predict the consequences of dysfunction on the upper urinary tract, and the outcome of the treatment being considered [3,4]. Uroflowmetry, cystometry, and pressure-flow study are components of urodynamics. The purpose of the uroflowmeter, which is performed without a catheter, is to measure the urine flow rate, which is defined as the amount of urine voided per unit time. Cystometry and pressure-flow study are the stages in which the response of the bladder to the filling process performed by placing the catheter and the relationship between the intrabladder pressure and the urine flow rate while the bladder is emptied are evaluated [5]. During urodynamics, many patients report physical and emotional discomfort such as pain (during catheter insertion), anxiety, and embarrassment [3,4,6,7]. However, although there is no evidence in the literature, it is reported that urination may be affected by anxiety and discomfort, especially during pressure-flow study, and for the patient, anxiety during the procedure may affect the initiation of the voiding reflex due to the detrusor function [8-11].

In infancy, the sound of running water in the sink has been used effectively for toilet training. Although the underlying mechanism is not fully understood, it is speculated that the sound of running water may increase the parasympathetic tone that powers the detrusor muscle and relax the resistant tone of the urethral sphincter, causing an increase in maximum urine flow rate, resulting in easy urination [12-14]. In a study conducted in a New York hospital in the early 1970s, the sound of running water had a positive effect on patients, including the effect on voiding [15]. Many healthy people often feel a strong urge to pee after hearing the sound of running water [14]. In addition, listening to the sound of running water in the care of patients who have difficulty in emptying urine is also applied as a nursing intervention [16].

Nurses perform their roles as educators and practitioners while informing the patient before urodynamics, giving the patient the appropriate position during the procedure, and making the necessary directions for the patient to express their feelings about voiding [17]. For urodynamics to give reliable results, it is important that the patient feels as comfortable and safe as possible during the procedure with a multidisciplinary approach. During urodynamics, many different methods (listening to music, applying hot pads, lavender aromatherapy, etc.) were used to reduce the discomfort and anxiety of the patients [1,4,18,19]. However, when the literature is examined, no study has been found that examines the effect of reducing anxiety in patients by listening to the sound of running water during urodynamics and the effect on urine flow rate during pressure-flow study. Therefore, this study was planned to determine the effect of listening to the sound of running water during urodynamics on the patient’s anxiety and parameters in the pressure-flow study.

When the characteristics of the patients included in the study were examined; more than half (55%) of them were women, their mean age was 57.93 ± 14.38 years. 76.7% of the patients had a chronic disease (20 patients with Diabetes Mellitus, 14 patients with Hypertension, 12 patients with cerebrovascular disease), 31.7% were using a clean intermittent catheter to empty their urine, 55% had difficulty micturation, 76.7% had urinary incontinence, and the average number of nocturia of the patients was 2.72 ± 2.56 (Table 1).

The patients in the control group had an anxiety score of before urodynamics 6.30 ± 1.78, during urodynamics 4.93 ± 1.84, and after urodynamics 5.03 ± 2.03. It was seen that the patients in the experimental group had an average anxiety score of before urodynamics 5.13 ± 3.66, during urodynamics 1.83 ± 2.77, and after urodynamics 1.43 ± 2.65 (Table 2). During the pressure-flow study, in the experimental group patients who listened to the sound of running water from a smartphone; anxiety level mean scores during and after urodynamics were found to be statistically significantly lower than the control group patients (P < 0.001) (Table 3).

The mean Qmax score of the patients in the control group was 5.20 ± 7.13, the mean PdetQmax score was 17.47 ± 24.84, the bladder outlet obstruction index mean score was 7.06 ± 19.85, the bladder contractility index mean score was 43.47 ± 54.33 (Table 2). The mean Qmax score of the patients in the experimental group is 8.27 ± 7.76, the mean PdetQmax score is 29.63 ± 24.57, the mean bladder outlet obstruction index score is 13.10 ± 25.02, the bladder contractility index mean score is 70.97 ± 51.53 (Table 2). It was observed that the mean bladder contractility index score in the experimental group patients was statistically significantly higher than the control group patients (P < 0.001). The cases of micturating with a catheter during the pressure-flow study were found to be statistically significantly higher in the experimental group patients than in the control group patients (P < 0.001) (Table 3).

As a result of this study, the effect of listening to the sound of running water during urodynamics on the parameters of the patient’s anxiety and pressure-flow study was determined. Due to the placement of urethral and rectal catheters during urodynamics, many patients experience discomfort and anxiety during urodynamics. In addition, the anxiety of not protecting privacy during urodynamics and lack of knowledge about the application may also cause anxiety in patients [4,21,22]. As intimacy declines, even individuals without paruresis report mild difficulty initiating urination [10]. In this context, some patients fail to void during urodynamics, and this failure leads to feelings of anxiety and embarrassment. Herd [23] states that most of the patients undergoing urodynamics experience serious anxiety and discomfort due to voiding. However, it has been reported in the literature that urination may be affected by anxiety and discomfort, especially during pressure-flow study, and anxiety may affect the initiation of the voiding reflex due to its detrusor function [8-11]. Zelikovsky et al. [24] states that it is important to reduce the distress of patients and encourage urination with different applications during procedures such as urodynamics. In the literature, it is stated that listening to music during invasive procedures such as bronchoscopy, colonoscopy and cystoscopy helps patients experience less pain and anxiety [25]. It has been reported that listening to music during urological interventions (cystoscopy, prostate biopsy) is effective in reducing the anxiety and discomfort levels of patients [19,25-27]. In this study, like the literature, the mean scores of anxiety level during and after urodynamics in the experimental group patients who listened to the sound of running water from a smartphone during the pressure-flow study were lower than the control group patients.

The Qmax values and PdetQmax values of the patients in the experimental group were found to be higher during the pressure-flow study. Parasympathetic tone increases with the sound of running water, resulting in stronger detrusor contractions [28]. In addition, it was observed that Qmax values increased with the relaxation in the external urethral sphincter [29]. Kwon et al. [14] had patients listen to the sound of running water using a mobile phone application during urodynamics and an increase in peak flow rate was observed in this group. It is thought that the running water sound listened to in the study has a positive effect on the detrusor muscle and increases the maximum urination speed by reducing the anxiety caused by an invasive procedure such as urodynamics.

It has been revealed in previous studies that the urge to urinate is felt with the sound of water [14]. A Pavlovian mechanism brings the feeling of urination, as in the watering of the mouth reflex, when a dog understands that food will come when he hears the bell. In this study, the sound of running water was not listened to during the filling cystometry by paying attention to this situation. After the patients declared that they had reached the maximum cystometric capacity, the sound of running water was listened to when the pressure-flow study was started.

The study has some limitations. The first of these is that the experimental group was evaluated only with the sound of running water. No evaluation was made with other music genres. However, the fact that the sound of water was not heard during the free uroflowmeter is another limitation. Symptom questionnaires (such as International Prostate Symptom Score, International Consultation on Incontinence Questionnaire-Short Form, etc.) were not filled in because the preprocedural symptoms of the patients between the groups were similar. The lack of randomized control of the study is also among the limitations.

In conclusion, listening to the sound of running water during urodynamics had a positive effect on reducing anxiety in patients and micturating during pressure-flow study. In order for urodynamics to give reliable results and for the patient to feel as comfortable and safe as possible during the procedure, it is important to inform the patient before urodynamics, to give the patient the appropriate position during the procedure, and to provide necessary guidance during the procedure. However, the implementation of different practices that will reduce the distress of the patients and encourage urination during pressure-flow study requires a multidisciplinary approach. The obtained data will shed light on future randomized controlled studies with large number of patients.