This document discusses urodynamic testing, which involves physiological tests to investigate lower urinary tract function abnormalities. Key tests include cystometry to measure bladder pressure and volume relationships during filling, and uroflowmetry to measure urine flow rate. Cystometry parameters like compliance, first desire to void volume, and detrusor overactivity are evaluated. Urodynamic testing aims to characterize detrusor and bladder outlet function, reproduce symptoms, and determine their cause.
This document discusses urodynamic testing, which involves physiological tests to investigate lower urinary tract function abnormalities. Key tests include cystometry to measure bladder pressure and volume relationships during filling, and uroflowmetry to measure urine flow rate. Cystometry parameters like compliance, first desire to void volume, and detrusor overactivity are evaluated. Urodynamic testing aims to characterize detrusor and bladder outlet function, reproduce symptoms, and determine their cause.
This document discusses urodynamic testing, which involves physiological tests to investigate lower urinary tract function abnormalities. Key tests include cystometry to measure bladder pressure and volume relationships during filling, and uroflowmetry to measure urine flow rate. Cystometry parameters like compliance, first desire to void volume, and detrusor overactivity are evaluated. Urodynamic testing aims to characterize detrusor and bladder outlet function, reproduce symptoms, and determine their cause.
FUNCTION: Storage & Voiding Physiology of Micturition Physiology of Micturition
• Low bladder volumes: SNS is stimulated and PNS is
inhibited. • Bladder full: PNS stimulated (bladder contracts) SNS inhibited (internal sphincter relaxes). • Intravesical pressure > resistance within the urethra: urine flows. • Pudendal nerve innervates external sphincter. UDS Urodynamics describes a group of physiological tests that are used in clinical practice to investigate abnormalities of lower urinary tract function.
Dynamic study of transport, storage & evacuation of
urine.
Main goal of UDS: to reproduce pt.'s symptoms and
determine their cause by various tests. UDS Armamentarium Cystometry(most important test), filling cystometry & voiding cystometry Uroflowmetry Urethral pressure studies Pressure flow micturition studies Video-urodynamic studies Electromyography INDICATION SIncontinence: -incontinence in whom surgery is planned. -mixed ,urge & stress symptoms. -associated voiding problems. -pts. with neurologic disorders. INDICATIONS Outflow Obstruction: -pt with LUTS, at least uroflow study.
-kids with daytime urgency and urge incontinence, recurrent infection, reflux, or upper tract changes. Clinical role Characterization of detrusor function. Evaluation of bladder outlet. Evaluation of voiding function. Diagnosis and characterization of neuropathy. Three important rules before starting UDS evaluation:
1. Decide on questions to be answered before starting a
study. 2. Design the study to answer these questions. 3. Customize the study as necessary. Terminology for Common Urodynamic Terms and Observations According to the International Continence Society Standardization Subcommittee The ICS has now defined the term urodynamic observations to denote observations that occur during and are measured by the urodynamics(UDS) test itself. Two principal methods of urodynamic investigation exist: Conventional urodynamic studies: normally take place in the urodynamic laboratory involving artificial bladder filling. Ambulatory urodynamic studies: a functional test of the lower urinary tract using natural filling and reproducing the subject’s everyday activities. The following are required of both types of studies: Intravesical pressure: the pressure within the bladder. Abdominal pressure: the pressure surrounding the bladder; currently it is estimated from rectal, vaginal, or extraperitoneal pressure or a bowel stoma. Detrusor pressure: the component of intravesical pressure created by forces on the bladder wall that are both passive and active. Filling cystometry: the method by which the pressure and volume relationship of the bladder is measured during bladder filling. Physiologic filling rate: a filling rate less than the predicted maximum. Predicted maximum is the body weight in kilograms divided by 4 and expressed as milliliters per minute. Nonphysiologic filling rate: a filling rate greater than the predicted maximum. Urodynamic stress incontinence: noted during filling cystometry and defined as the involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction. This currently replaces genuine stress incontinence. Urethral pressure measurements: Urethral pressure: the fluid pressure needed to just open a closed urethra. Urethral pressure profile: a graph indicating the intraluminal pressure along the length of the urethra. Urethral closure pressure profile: the subtraction of intravesical pressure from urethral pressure. Maximum urethral pressure: the maximum pressure of the measured profile. Maximum urethral closure pressure (MUCP): the maximum difference between the urethral pressure and the intravesical pressure. Functional profile length: the length of the urethra along which the urethral pressure exceeds intravesical pressure in women. Abdominal leak point pressure(ALPP): the intravesical pressure at which urine leakage occurs because of increased abdominal pressure in the absence of a detrusor contraction. Detrusor leak point pressure(DLPP): the lowest detrusor pressure at which urine leakage occurs in the absence of either a detrusor contraction or increased abdominal pressure. CYSTOMETR Y Measurement of intravesical bladder pressure during bladder filling(measures volume-pressure relationships). Used to assess bladder sensation, capacity, compliance, detrusor activity. Bladder access by transurethral catheter, or rarely by percutaneous suprapubic tube. Filling medium either gas (CO2) or liquid (water, saline, or contrast material at body temp). Liquid cystometry is more physiologic. Ideally, filling should be performed in standing position. CYSTOMETRY Bladder filling either by diuresis or filling through a catheter. Filling slow (up to 10 ml/min), physiologic medium (10 to 100 ml/min) fast (> 100 ml/min) Children and pts with known bladder hyperactivity require slow fill rates. All systems should be zeroed to atmospheric pressure. No air bubbles. Phases of cystometrogram Normal CMG: - No leakage on coughing . - A voiding detrusor pressure - Capacity 350-600ml - First desire to void between rise of < 70 cm H2O with a • 150- 200 ml. peak flow rate of > 15 ml / s for a volume > 150 ml. - Constant low pressure that does not reach more than 6- 10 cm - Residual urine of < 50 ml. H2O above baseline at the end of filling. - Provocative maneuvers(cough, fast fill etc.) should not provoke a bladder contraction normally. CYSTOMETRY(contd...) Single Vs multi-channel UDS: -single: Pves only -multi: Pves, Pdet, Pabd CMG PARAMETERS Intravesical pressure(Pves): Total Pressure within the bladder. Abdominal pressure(Pabd): Pressure surrounding the bladder; currently estimated from rectal, vaginal, or extraperitoneal pressure or a bowel stoma. Detrusor pressure(Pdet): Component of intravesical pressure created by forces on the bladder wall, both passive and active. True detrusor pressure = Intravesical pressure - Intraabdominal pressure.(Pdet = Pves-Pabd) Physiologic filling rate: A filling rate < predicted maximum. Predicted maximum = body weight in kg divided by 4 and expressed as ml/min. Nonphysiologic filling rate: A filling rate > predicted maximum. First sensation of bladder filling: Volume at which patient first becomes aware of bladder filling. First desire to void: Feeling during filling cystometry that would lead the patient to pass urine at the next convenient moment. Strong desire to void: Persistent desire to void without fear of leakage. Compliance: - Relationship between change in bladder volume and change in Pdet (Δvolume/Δpressure); measured in ml/cm H2O. - Normal bladder is highly compliant, and can hold large volumes at low pressure. - Normal pressure rise during the course of CMG in normal bladder will be only 6-10 cm H2O. - Decrease compliance < 20 ml/cm H2O, poorly distensible bladder. Impaired compliance is seen in: neurologic conditions: spinal cord injury/lesion, spina bifida, usually results from increased outlet resistance (e.g., detrusor external sphincter dyssynergia [DESD]) or decentralization in the case of lower motor neuron lesions, Long-term BOO (e.g., from benign prostatic obstruction), Structural changes- radiation cystitis or tuberculosis. Impaired compliance with prolonged elevated storage pressures is a urodynamic risk factor and needs treatment to prevent renal damage. Neurogenic detrusor overactivity: Overactivity accompanied by a neurologic condition; also k/a detrusor hyperreflexia.
Idiopathic detrusor overactivity: Detrusor
overactivity without concurrent neurologic cause; also k/a detrusor instability. Abdominal leak point pressure(ALPP): Intravesical pressure at which urine leakage occurs because of increased abdominal pressure in the absence of a detrusor contraction. ALPP is a measure of sphincteric strength or ability of the sphincter to resist changes in Pabd Applicable to stress incontinence; ALPP can be demonstrated only in a patient with SUI. There is no normal ALPP, because patients without stress incontinence will not leak at any physiologic Pabd. Lower the ALPP, weaker is the sphincter. ALPP<60 cm H2O: significant ISD ALPP 60-90 cm H2O: equivocal ALPP>90 cm H2O: urethral hypermobility; little or no ISD Detrusor leak point pressure(DLPP): Lowest detrusor pressure at which urine leakage occurs in the absence of either a detrusor contraction or increased abdominal pressure (risk with > 40cm H2O). Its a measure of Pdet in a patient with decreased bladder compliance. Higher the urethral resistance, higher the DLPP, the more likely is upper tract damage as intravesical pressure is transferred to the kidneys. UROFLOMETRY Non invasive study. Measurement of the rate of urine flow over time. Estimate of effectiveness of the act of voiding along with PVR. Influenced by effectiveness of detrusor contraction completeness of sphincteric relaxation patency of the urethra 3 methods used gravimetric rotating disk electronic dipstick Recorded variables during UFM study: Voided volume (VV in milliliters) • Flow rate (Q in milliliters per second) • Maximum flow rate (Qmax in milliliters per second) • Average flow rate (Qave in milliliters per second) • Voiding time (total time during micturition in seconds) • Flow time (the time during which flow occurred in seconds) • Time to maximum flow (onset of flow to Qmax in seconds) • Optimal voids 200 to 400cc. • Voids < 150cc are difficult to interpret. • Pt. should be well hydrated with full bladder, but not overly distended bladder. • Should be performed in privacy and pt.encouraged to void in his normal fashion. • Qmax & shape of curve- more reliable indicators of BOO. • Qmax- most reliable variable in detecting abnormal voiding. Normal uroflow curve is bell-shaped Flattened pattern: Obstruction Interrupted or straining pattern: Impaired bladder contractility, obstruction, or voiding with/by abdominal straining. "Box-pattern" : Urethral Stricture Post Void Residual Urine
Excellent assessment of bladder emptying.
Performed by ultrasound (bladder scan) or catheterization. Normally, it is < 0.5ml, but < 10% of voided volume is considered insignificant. Urethral pressure profilometry
Urethral pressure profile (UPP): a graph indicating
intraluminal pressure along the length of urethra. Urethral pressure: fluid pressure needed to just open a closed urethra. UPP is obtained by withdrawal of a pressure sensor (catheter) along the length of urethra. UPP Parameters: Urethral closure pressure profile is given by subtraction of intravesical pressure from urethral pressure. Maximum urethral pressure is highest pressure measured along the UPP. • Maximum urethral closure pressure (MUCP) : maximum difference between urethral pressure and intravesical pressure. Functional profile length: length of urethra along which urethral pressure exceeds intravesical pressure in women. In most continent women, functional urethral length:approx.3 cm & MUCP is 40 to 60 cm H2O. MUCP is not always indicative of severity of incontinence hence not used commonly. UPP PRESSURE FLOW MICTURITION STUDIES Simultaneous measurement of bladder pressure and flow rate throughout the micturition cycle. Best method of quantitatively analyzing voiding function. Access to bladder via transurethral or SPC 8F or less. Intra-abdominal pressure measured by balloon catheter in rectum or vagina. Men should void in standing position, while women seated on commode. Detrusor pressure at maximal flow(Pdet at Qmax): Magnitude of micturition contraction at the time when flow rate is at its maximum. Pressure <100 cm H2O indicate outlet obstruction even if the flow rate is normal. Normal male generally voids with Pdet 40-60 cm H2O and woman with lower pressure. Pdet more accurately measures bladder wall contractions. Indications for pressure-flow studies: - to differentiate between pts with a low Qmax sec. to obstruction, from those sec.to poor contractility. - Identify pt.with normal flow rates but high pressure obstruction. - LUTS in pt with hx of neurologic disease(CVA, Parkinson’s). - LUTS with normal flow rates (Qmax > 15cc/min). younger men with LUTS.
- Men with little endoscopic evidence of
prostate occlusion ICS provisional nomogram VIDEO-URODYNAMICS UDS with simultaneous fluoroscopic image of lower urinary tract. Equipment and technique: - CMG + PFS same as before but the study is conducted on a fluoroscopy table, and the filling medium is a radiographic contrast agent. clinical applicability: complex BOO evaluation of VUR during storage &/or filling. neurogenic bladder dysfunction identification of associated pathology Primary BNO diagnosis & differentiation from dysfunctional voiding in women: only on VUDS. Video-urodynamics ELECTROMYOGRAPHY (EMG) Study of the electric potentials produced by depolarization of muscle membranes. In case of UDS, EMG measurement of striated sphincteric muscles of the perineum is done to evaluate possible abnormalities of pelvic floor muscle function. EMG activity is measured during both filling and emptying. EMG is performed via electrodes placed in (needle electrodes) or near (surface electrodes) the muscle to be measured. Most important information obtained from sphincter EMG is whether there is coordination or not between the external sphincter and the bladder.
EMG activity gradually increases during filling
cystometry (recruitment) and then cease and remains so for the time of voiding. Failure of the sphincter to relax or stay completely relaxed during micturition is abnormal. In pt with neurologic disease, this is called detrusor- sphincter dyssenergia. In the absence of neurologic disease, it is called pelvic floor hyperactivity,or dysfunctional voiding. CYSTOMETROGRAP H URODYNAMIC RISK FACTORS Following urodynamics findings are potentially dangerous and usually require intervention to prevent upper and lower urinary tract decompensation: 1. Impaired compliance 2. Detrusor external sphincter dyssynergia (DESD) 3. Detrusor internal sphincter dyssynergia (DISD) 4. High-pressure detrusor overactivity present throughout filling 5. Elevated detrusor leak point pressure (>40 cm H2O) 6. Poor emptying with high storage pressures