Urodynamics

(all you need to know in 30 minutes)

Rustom Manecksha
 Urodynamics

• The investigation of the function of the

lower urinary tract - the bladder and
urethra - using physical measurements
such as urine pressure and flow rate as
well as clinical assessment
 Aims of urodynamics

1. To reproduce the patient’s symptomatic

complaints
2. To provide a pathophysiological
explanation for the patient’s problems
Mechanism of urine storage
• As the bladder fills,
sensory receptors in
the bladder wall trigger
the micturition reflex
• Inhibited during filling
resulting in contraction
of the external
sphincter and inhibition
of detrusor contraction,
maintaining continence.
Mechanism of voiding
• Afferent pelvic nerve
discharges ascend in
spinal cord, synapse in
pontine micturition
centre
• Descending efferent
pathways cause:
– relaxation of sphincter
– bladder neck to open
– detrusor contraction
 Filling
BLADDER
• Low pressure,
compliant reservoir
P

URETHRA
• Closure pressure
must exceed bladder
P pressure
• Reflex closure
 Voiding
BLADDER
• Coordinated contraction
causes rise in pressure
P • Complete emptying

URETHRA
• Relaxation
P
bladder)
Pressure (in
Normal filling & voiding

Volume
 Urodynamics – spectrum of tests
Simple urodynamics Complex urodynamics
• Freq – volume charts • Urethral pressure
• Pad testing measurement
• Uroflowmetry • Neurophysiological
• Cystometry investigations
• Videocystometrography • Upper tract
urodynamics (e.g.
• Ambulatory
the Whitaker Test)
urodynamics
INVESTIGATION SYMPTOMS POSSIBLE DIAGNOSIS

Uroflow Frequency, nocturia, poor flow Bladder outlet obstruction

Pressure flow Frequency, nocturia, poor flow Bladder outlet obstruction

Cystometry Frequency, urgency Detrusor instability

Urethral closure
Incontinence Genuine stress incontinence
pressure

Frequency, urgency pointing to

Ambulatory Detrusor instability, Genuine
unstable bladder but not shown
urodynamics stress incontinence
on staticurodynamics
 Frequency – volume charts
• Patient is instructed to
hold-on to maximum
capacity before each
voiding over 48-72
hours and measure
the volume and time
of each void on a
chart
 Pad testing
• The subjective assessment of
incontinence is difficult to interpret and
may not indicate reliably the degree of
abnormality.
• Problems with test:
– Drying out
– Perspiration & vaginal discharge
– Compliance
– Weighing scale accuracy
 Uroflowmetry
• The simplest assessment of voiding
dysfunction – measurement of urinary flow
rate
• Often possible to confirm the presence of
bladder outflow obstruction
• Device that measures and indicates the
volume of fluid passed per unit time (ml/s)
• Often coupled with post-void bladder scan
 Practical tips
• Consider the rate and the pattern
• Voided volumes <150-200 ml  unreliable
results
• Patient should be in favourable
surroundings & should not be unduly
stressed
 Uroflowmetry
Unobstructed Obstructed

• Qmax = 19ml/s • Qmax = 7 ml/s

• The shape of the curve is • The shape of the curve is
unimodal (i.e. monotonic unimodal (i.e. monotonic
increase, stable period, increase, stable period,
monotonic decrease) monotonic decrease)
• Consider poorly contracting
bladder
 Key parameters
• Voided vol. > 150 ml

• Qmax > 15 ml/s – unlikely obstructed

10-15ml/s – equivocal
< 10 ml/s – possibly obstructed
or weak detrusor
activity

• PVRV - incomplete bladder emptying

 Cystometry
• Measures the pressure/volume relationship
of the bladder
• Measurement of detrusor pressure during
controlled bladder filling and subsequent
voiding with measurement of flow rate
• Used to assess detrusor activity, sensation,
capacity and compliance
 Detrusor pressure
• Cannot be measured
• It is estimated/calculated by the automatic
subtraction of rectal pressure (an index of
IAP) from the total bladder pressure, thus
removing the influence of artefacts
produced by abdominal straining

Pdet = Pves - Pabd

 4 simple questions

1. Is the bladder relaxed during filling?

2. Is the urethra contracted during filling?
3. Does the bladder contract adequately
during voiding?
4. Does the urethra open properly during
voiding?
 Principles
• If a change is seen in both Pves and Pabd
but not in Pdet, then it is due to raised IAP
• If a pressure change is seen on Pves and
Pdet and not on Pabd, then it is due to a
detrusor contraction
• If a change is seen on Pves, Pabd and Pdet,
then there is both a detrusor contraction
and raised IAP
 Technique – filling cystometry
• 4 essential measurements:
1. Intravesical pressure (Pves)
2. Rectal pressure [≡abdominal] (Pabd)
3. Detrusor pressure (Pdet = Pves – Pabd)
4. Urine flow rate to detect leaks
• Other optional measurements include:
1. Bladder volume
2. Electromyography
3. Urethral pressure
 Filling
• Pves is measured via a urethral catheter
• Bladder is filled via UC (sterile H20 or 0.9% NaCl)
• Filling should be done with patient
standing (or sitting, for females)
• Slow-fill 10 ml/min
• Medium-fill 10-100 ml/min
• Fast-fill > 100 ml/min
 Bladder sensation
• Assessed during filling
– First DV normally about 50% bladder capacity
– Normal DV The feeling that leads patient to void at
next convenient moment; about
75% bladder capacity
– Strong DV Persistent desire to void without fear of
leakage; about 90% bladder
capacity)
– Urgency persistent desire to void with fear of
leakage
– Pain Pain during filling or voiding is
abnormal
 Detrusor activity
• During filling this can be either normal or
increased (overactivity)
• Detrusor overactivity exists, when, during
the filling phase, there are involuntary
detrusor contractions
 Measurements during voiding
• Premicturition pressure - the pressure recorded just
before the initial
isovolumetric contraction
• Opening time - time between initial rise in
detrusor pressure to the onset
of flow
• Opening pressure - pressure recorded at the onset
of measured flow
• Maximum pressure - max value of measured
pressure
• Pressure at max flow - pressure recorded at Qmax
 Pressure – flow plots
• The definitive way to diagnose BOO
• The Abrams Griffiths nomogram was
devised as the best method for separating
the pressure flow loops

The assessment of prostatic obstruction from urodynamic measurements and from residual
urine.
Abrams PH. Griffiths DJ . British Journal of Urology. 51(2):129-34, 1979
 Pressure-flow loops with Abrams &
Griffith nomogram

Low pressure high flow. The normal urethra is Unobstructed pressure Flow loop. The tip of the
highly distensible and opens at low pressures. loop is well into the unobstrcuted zone.
High pressure low flow; if the normal detrusor is Note that this is displayed on a different scale
obstructed to give low flow rates it will produce because of the high detrusor pressure. The
high pressures. patient is highly obstructed.
Normal / stable bladder
Unstable bladder
Detrusor-sphincter-dyssynergia
• Seen only in patients with neurological
disease
• Characterised by phasic contractions of
the intrinsic urethral striated muscle during
detrusor contraction
• This produces a very high voiding
pressure and an interrupted flow
 Videocystometography
• Uses contrast medium instead of saline
• Assesses position and mobility of bladder
neck
• Diagnoses diverticulae or reflux
• Expensive
• Involves radiation
• Useful in complex cases where equivocal
results from other tests; apparent failure of a
previous surgical procedure
 2002 ICS Terminology
• Detrusor instability – old
• (Idiopathic) detrusor overactivity – new
• Detrusor overactivity is a urodynamic
diagnosis
– i.e. urodynamically demonstrable involuntary bladder
contractions

• OAB is a clinical (empirical) diagnosis

Abrams et al. Neurourol Urodynam 2002; 21:167-78

 Points to think about
1. What is the role of urodynamics in the
evaluation of men with BOO
2. Role of urodynamics in women with
urgency and urge incontinence
3. Role of urodynamics in patients with
mixed UI and SI