URODYNAMIC EVALUATION
GovtRoyapettahHospit
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About This Presentation
URODYNAMIC EVALUATION
Slide Content
Latha .G
UrodynamicEvaluation of
Voiding Dysfunction
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
UrodynamicEvaluation of
Voiding Dysfunction
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2
History
Urodynamicswas first defined by David M. Davis in 1953
The study of the storage and emptying phases of the
urinary bladder ( Davis, 1953 ).
The cystometrograph, introduced in 1927 by D. K. Rose, was one
of the earliest urodynamicinstruments for measuring bladder
pressure during filling and voiding ( Rose, 1927 ).
This was followed by the uroflowmeterby Drake in 1948 .
In the 1950s, the development of simultaneous radiographic
imaging done in conjunction with physiologic studies was
pioneered by Hinmanand Miller ( Hinmanet al, 1954 ).
3Dept of Urology, GRH and KMC, Chennai.
Urodynamicswas first defined by David M. Davis in 1953
The study of the storage and emptying phases of the
urinary bladder ( Davis, 1953 ).
The cystometrograph, introduced in 1927 by D. K. Rose, was one
of the earliest urodynamicinstruments for measuring bladder
pressure during filling and voiding ( Rose, 1927 ).
This was followed by the uroflowmeterby Drake in 1948 .
In the 1950s, the development of simultaneous radiographic
imaging done in conjunction with physiologic studies was
pioneered by Hinmanand Miller ( Hinmanet al, 1954 ).
3Dept of Urology, GRH and KMC, Chennai.
Today, the urodynamicarmamentarium is
uroflowmetryand
cystometryas well as
pressure-flow studies,
electrophysiologicstudies,
urethral pressure studies, and
videourodynamicstudies.
4Dept of Urology, GRH and KMC, Chennai.
uroflowmetryand
cystometryas well as
pressure-flow studies,
electrophysiologicstudies,
urethral pressure studies, and
videourodynamicstudies.
4Dept of Urology, GRH and KMC, Chennai.
Nitti noted three important principles in
urodynamics:
(1) a study that does not duplicate the patient's
symptoms is not diagnostic,
(2) failure to record an abnormality does not rule
out its existence, and
(3) not all abnormalities detected are clinically
significant ( Nitti and Combs, 1998 ).
5Dept of Urology, GRH and KMC, Chennai.
urodynamics:
(1) a study that does not duplicate the patient's
symptoms is not diagnostic,
(2) failure to record an abnormality does not rule
out its existence, and
(3) not all abnormalities detected are clinically
significant ( Nitti and Combs, 1998 ).
5Dept of Urology, GRH and KMC, Chennai.
Aim of urodynamics
The aim of clinical urodynamicsis to
reproduce symptoms while making precise
measurements of the bladder physiology.
6Dept of Urology, GRH and KMC, Chennai.
The aim of clinical urodynamicsis to
reproduce symptoms while making precise
measurements of the bladder physiology.
6Dept of Urology, GRH and KMC, Chennai.
Indications and Selection of Patients for Conduction of
Urodynamics
I.Patients in whom potential therapy may be hazardous where one
would want to be sure of the correct diagnosis before instituting
therapy
II.Patients with recurrent incontinence in whom surgery is planned
III.Patients with incontinence and a confusing mix of stress and urge
symptoms and those with associated voiding problems
IV.Patients with neurologic disorders and those with a mismatch
between symptoms and clinical findings
Patients with LUTS suggestive of bladder outlet obstruction
7Dept of Urology, GRH and KMC, Chennai.
Urodynamics
I.Patients in whom potential therapy may be hazardous where one
would want to be sure of the correct diagnosis before instituting
therapy
II.Patients with recurrent incontinence in whom surgery is planned
III.Patients with incontinence and a confusing mix of stress and urge
symptoms and those with associated voiding problems
IV.Patients with neurologic disorders and those with a mismatch
between symptoms and clinical findings
Patients with LUTS suggestive of bladder outlet obstruction
7Dept of Urology, GRH and KMC, Chennai.
V. Patients with LUTS who have both obstructive and marked
instability symptoms
VI. Patients with obstructive LUTS and neurologic disease
Young men with LUTS
VII. All neurologically impaired patients who have neurogenic
bladder dysfunction
VIII. Children with daytime urgency and urge incontinence
IX. Children with persistent diurnal enuresis
X. Children with spinal dysraphism
8Dept of Urology, GRH and KMC, Chennai.
instability symptoms
VI. Patients with obstructive LUTS and neurologic disease
Young men with LUTS
VII. All neurologically impaired patients who have neurogenic
bladder dysfunction
VIII. Children with daytime urgency and urge incontinence
IX. Children with persistent diurnal enuresis
X. Children with spinal dysraphism
8Dept of Urology, GRH and KMC, Chennai.
PREPARATION OF PATIENTS AND
PRECAUTIONS
prestudydiscussion of the study technique and
counseling about the risks are appropriate
During the study, the patient should understand what
information we are trying to collect sufficiently to be
able to volunteer timely responses to changing events.
Some may have been started empirically on medication
for their symptoms including anticholinergics, α
blockers, bladder relaxation medications, and
psychotropic medications. These affect urodynamic
outcomes and should be stopped with an adequate
washout period prior to the test.
9Dept of Urology, GRH and KMC, Chennai.
PRECAUTIONS
prestudydiscussion of the study technique and
counseling about the risks are appropriate
During the study, the patient should understand what
information we are trying to collect sufficiently to be
able to volunteer timely responses to changing events.
Some may have been started empirically on medication
for their symptoms including anticholinergics, α
blockers, bladder relaxation medications, and
psychotropic medications. These affect urodynamic
outcomes and should be stopped with an adequate
washout period prior to the test.
9Dept of Urology, GRH and KMC, Chennai.
An adequate history and physical examination
should be performed before the test and
a voiding diary completed to determine the
functional capacity, daily urine output, and
approximate filling volume
10Dept of Urology, GRH and KMC, Chennai.
should be performed before the test and
a voiding diary completed to determine the
functional capacity, daily urine output, and
approximate filling volume
10Dept of Urology, GRH and KMC, Chennai.
Antibiotics
Pretest urinalysis is negative for infection
Parenteralantibiotic prophylaxis may be necessary in
specific patients, such as those with cardiac valve
abnormalities, orthopedic prostheses, genitourinary
prostheses, pacemakers, and other electrical devices
patients with total joint replacements within 2 years
after implant surgery, immunocompromised patients,
and those with previous prosthetic joint infections (
American Urological Association Advisory Statement,
2002 ).
11Dept of Urology, GRH and KMC, Chennai.
Pretest urinalysis is negative for infection
Parenteralantibiotic prophylaxis may be necessary in
specific patients, such as those with cardiac valve
abnormalities, orthopedic prostheses, genitourinary
prostheses, pacemakers, and other electrical devices
patients with total joint replacements within 2 years
after implant surgery, immunocompromised patients,
and those with previous prosthetic joint infections (
American Urological Association Advisory Statement,
2002 ).
11Dept of Urology, GRH and KMC, Chennai.
The UrodynamicsRoom
The room used for urodynamicsshould be without
distractions, quiet, and protected from unnecessary
interruptions.
The room should be large enough for the physician
to perform a physical and pelvic examination,
to place catheters, and
to move unencumbered within the room.
One should always take into account the need for
sufficient room to allow for wheelchairs and assist
devices such as walkers.
12Dept of Urology, GRH and KMC, Chennai.
The room used for urodynamicsshould be without
distractions, quiet, and protected from unnecessary
interruptions.
The room should be large enough for the physician
to perform a physical and pelvic examination,
to place catheters, and
to move unencumbered within the room.
One should always take into account the need for
sufficient room to allow for wheelchairs and assist
devices such as walkers.
12Dept of Urology, GRH and KMC, Chennai.
URODYNAMIC EQUIPMENT
Three measurement
channels,
two for pressure and
one for flow;
a display (on either a
printer or a monitor); and
a method for secure
storage of the recorded
pressures (abdominal,
vesicle, detrusor) and
flow measurements as
tracings against time (
Schafer et al, 2002 ).
13Dept of Urology, GRH and KMC, Chennai.
Three measurement
channels,
two for pressure and
one for flow;
a display (on either a
printer or a monitor); and
a method for secure
storage of the recorded
pressures (abdominal,
vesicle, detrusor) and
flow measurements as
tracings against time (
Schafer et al, 2002 ).
13Dept of Urology, GRH and KMC, Chennai.
The infused volume and voided volume may be recorded
graphically or numerically.
all measured and derived signals must be displayed
continuously over time according to ICS standards,
preferably with the following sequential position of
tracings:
from top down on the page
Pabd(abdominal pressure),
Pves(vesicalpressure),
Pdet(detrusorpressure), and
flow (Q).
Filling volume,
electromyography (EMG), and
voided volumes may be displayed.
14Dept of Urology, GRH and KMC, Chennai.
graphically or numerically.
all measured and derived signals must be displayed
continuously over time according to ICS standards,
preferably with the following sequential position of
tracings:
from top down on the page
Pabd(abdominal pressure),
Pves(vesicalpressure),
Pdet(detrusorpressure), and
flow (Q).
Filling volume,
electromyography (EMG), and
voided volumes may be displayed.
14Dept of Urology, GRH and KMC, Chennai.
Catheters
The standard catheter for routine urodynamicsis a
transurethral, double-lumen catheter .
Suprapubicplacement has been used in patients with
obstruction such as urethral stricture disease,
The smallest available is the 6 Fr double-lumen
catheter.
This allows the fill and void sequence to be repeated
without recatheterization.
similarly sized triple-lumen catheters are available
that allow bladder filling, intravesicalpressure
measurement, and urethral pressure recording.
15Dept of Urology, GRH and KMC, Chennai.
The standard catheter for routine urodynamicsis a
transurethral, double-lumen catheter .
Suprapubicplacement has been used in patients with
obstruction such as urethral stricture disease,
The smallest available is the 6 Fr double-lumen
catheter.
This allows the fill and void sequence to be repeated
without recatheterization.
similarly sized triple-lumen catheters are available
that allow bladder filling, intravesicalpressure
measurement, and urethral pressure recording.
15Dept of Urology, GRH and KMC, Chennai.
The use of a balloon catheter is best for the
measurement of abdominal pressure.
An air-free balloon in the rectum or in the vagina
in women.
The balloon maintains a small fluid volume at the
catheter opening to avoid fecal blockage
preventing pressure transmission.
16Dept of Urology, GRH and KMC, Chennai.
measurement of abdominal pressure.
An air-free balloon in the rectum or in the vagina
in women.
The balloon maintains a small fluid volume at the
catheter opening to avoid fecal blockage
preventing pressure transmission.
16Dept of Urology, GRH and KMC, Chennai.
Flowmeters
The flow rate is measured by a uroflowmeterwith the
SI unit for flow being cubic meters per second
(m
3
/sec) and for mass flow rate kilograms per second
(kg/sec)
Most flow rates are reported in milliliters per second
(mL/sec) .
Most flowmetersare calibrated for water, which has a
density of 1; therefore, the mass of the fluid in grams
equals the volume in milliliters.
17Dept of Urology, GRH and KMC, Chennai.
The flow rate is measured by a uroflowmeterwith the
SI unit for flow being cubic meters per second
(m
3
/sec) and for mass flow rate kilograms per second
(kg/sec)
Most flow rates are reported in milliliters per second
(mL/sec) .
Most flowmetersare calibrated for water, which has a
density of 1; therefore, the mass of the fluid in grams
equals the volume in milliliters.
17Dept of Urology, GRH and KMC, Chennai.
UrodynamicsEquations
1.Flow rate:
Flow is the change in volume over the change in time: q = dV/dt:
flow rate (Q), volume (V), time (T),
2.Compliance:
C (compliance) = dV/dPdet(detrusorpressure).
3.Detrusorpressure:
pdet= pves-pabd,
pdet(detrusorpressure), pves(vesicalpressure), pabd(abdominal
pressure).
4.Physiologic filling rate for cystometry:
rate = body weight (in kg)/4, expressed as mL/min.
18Dept of Urology, GRH and KMC, Chennai.
1.Flow rate:
Flow is the change in volume over the change in time: q = dV/dt:
flow rate (Q), volume (V), time (T),
2.Compliance:
C (compliance) = dV/dPdet(detrusorpressure).
3.Detrusorpressure:
pdet= pves-pabd,
pdet(detrusorpressure), pves(vesicalpressure), pabd(abdominal
pressure).
4.Physiologic filling rate for cystometry:
rate = body weight (in kg)/4, expressed as mL/min.
18Dept of Urology, GRH and KMC, Chennai.
Types of Flowmeter
Gravimetric flowmetersoperate by measuring the weight of the
collected fluid or by measuring the hydrostatic pressure at the
base of the collecting cylinder.
The electronic dip stick flowmetermeasures the electrical
capacitance of a dipstick mounted in a collecting chamber.
In the rotating disk flowmeterthe voided fluid is directed onto a
rotating disk. The power required to keep the disk rotating at a
constant rate is measured and proportional to the mass flow rate
of the fluid.
Today, most available flowmetersare gravimetric or rotating disk
transducers. 19Dept of Urology, GRH and KMC, Chennai.
Gravimetric flowmetersoperate by measuring the weight of the
collected fluid or by measuring the hydrostatic pressure at the
base of the collecting cylinder.
The electronic dip stick flowmetermeasures the electrical
capacitance of a dipstick mounted in a collecting chamber.
In the rotating disk flowmeterthe voided fluid is directed onto a
rotating disk. The power required to keep the disk rotating at a
constant rate is measured and proportional to the mass flow rate
of the fluid.
Today, most available flowmetersare gravimetric or rotating disk
transducers. 19Dept of Urology, GRH and KMC, Chennai.
Electromyography Equipment
EMG is the study of the electrical potentials produced
by the depolarization of muscle membranes.
The depolarization must first be detected by an
electrode placed close to the origin of the signal.
These include intramuscular needle electrodes and
surface electrodes placed on the skin or mucosa
overlying the muscle of interest.
20Dept of Urology, GRH and KMC, Chennai.
EMG is the study of the electrical potentials produced
by the depolarization of muscle membranes.
The depolarization must first be detected by an
electrode placed close to the origin of the signal.
These include intramuscular needle electrodes and
surface electrodes placed on the skin or mucosa
overlying the muscle of interest.
20Dept of Urology, GRH and KMC, Chennai.
Types of Electrodes
Self-adhesive, skin patch electrodesprovide good surface recordings and
allow patients mobility. These electrodes are predominantly used in
pediatric urodynamics.
Needle electrodesprovide better recording quality and specificity for
certain muscle groups.
Wire electrodesare made of stainless steel, platinum, or copper wire. The
wire is placed into the muscle to be studied through a needle acting as a
cannula.
Monopolarelectrodesare thin needles coated with an insulating
material with an exposed tip. They need a reference electrode, a small
metal disk attached to the skin near the muscle being examined.
Concentric electrodesconsist of a wire inside an outer cannula,
separated by insulating material. The outer, conductive portion serves as
the ground. This can record from one to three motor units
simultaneously.
21Dept of Urology, GRH and KMC, Chennai.
Self-adhesive, skin patch electrodesprovide good surface recordings and
allow patients mobility. These electrodes are predominantly used in
pediatric urodynamics.
Needle electrodesprovide better recording quality and specificity for
certain muscle groups.
Wire electrodesare made of stainless steel, platinum, or copper wire. The
wire is placed into the muscle to be studied through a needle acting as a
cannula.
Monopolarelectrodesare thin needles coated with an insulating
material with an exposed tip. They need a reference electrode, a small
metal disk attached to the skin near the muscle being examined.
Concentric electrodesconsist of a wire inside an outer cannula,
separated by insulating material. The outer, conductive portion serves as
the ground. This can record from one to three motor units
simultaneously.
21Dept of Urology, GRH and KMC, Chennai.
CONDUCTING THE URODYNAMIC
EVALUATION
22Dept of Urology, GRH and KMC, Chennai.
EVALUATION
22Dept of Urology, GRH and KMC, Chennai.
Uroflow
Uroflowmetryis noninvasive, inexpensive, and
invaluable in screening patients with voiding
dysfunction.
This noninvasive test should precede any other
urodynamicstudies.
It is easy to perform and quickly provides data on both
storage and voiding symptoms.
Ideally, two or more tests should be performed, and
the addition of a noninvasive postvoidresidual volume
measurement by ultrasound adds to the value of the
study.
23Dept of Urology, GRH and KMC, Chennai.
Uroflowmetryis noninvasive, inexpensive, and
invaluable in screening patients with voiding
dysfunction.
This noninvasive test should precede any other
urodynamicstudies.
It is easy to perform and quickly provides data on both
storage and voiding symptoms.
Ideally, two or more tests should be performed, and
the addition of a noninvasive postvoidresidual volume
measurement by ultrasound adds to the value of the
study.
23Dept of Urology, GRH and KMC, Chennai.
Normal voiding includes
a detrusormuscle contraction,
coordinated bladder outlet relaxation,
low voiding pressure, and
a smooth, arc-shaped flow curve ( Schafer et al,
2002 ).
The flow pattern-the shape of the flow tracing,
sometimes be used to make a presumptive
diagnosis.
24Dept of Urology, GRH and KMC, Chennai.
a detrusormuscle contraction,
coordinated bladder outlet relaxation,
low voiding pressure, and
a smooth, arc-shaped flow curve ( Schafer et al,
2002 ).
The flow pattern-the shape of the flow tracing,
sometimes be used to make a presumptive
diagnosis.
24Dept of Urology, GRH and KMC, Chennai.
The normal flow
pattern is a
continuous, bell-
shaped, smooth curve
with a rapidly
increasing flow rate
25Dept of Urology, GRH and KMC, Chennai.
pattern is a
continuous, bell-
shaped, smooth curve
with a rapidly
increasing flow rate
25Dept of Urology, GRH and KMC, Chennai.
The typical obstructed flow pattern has a plateau-
shaped curve with a prolonged flow time,
sustained low flow rate, and increased time to
Qmax.
An intermittent flow pattern is one that has one
or several episodes of flow increasing or
decreasing (or ceasing completely) and is
commonly secondary to abdominal straining or
external sphincter spasm (e.g., detrusor-sphincter
dyssynergia).
26Dept of Urology, GRH and KMC, Chennai.
shaped curve with a prolonged flow time,
sustained low flow rate, and increased time to
Qmax.
An intermittent flow pattern is one that has one
or several episodes of flow increasing or
decreasing (or ceasing completely) and is
commonly secondary to abdominal straining or
external sphincter spasm (e.g., detrusor-sphincter
dyssynergia).
26Dept of Urology, GRH and KMC, Chennai.
Data from the uroflowcurve include
maximum flow rate,
total voided volume,
average flow rate, and
the postvoidresidual.
The curve shape and Qmaxis volume dependent, only
voided volumes of at least 150 mLshould be
interpreted .
The maximum flow rate should always be
documented together with the total voided volume
and postvoidresidual volume.
27Dept of Urology, GRH and KMC, Chennai.
maximum flow rate,
total voided volume,
average flow rate, and
the postvoidresidual.
The curve shape and Qmaxis volume dependent, only
voided volumes of at least 150 mLshould be
interpreted .
The maximum flow rate should always be
documented together with the total voided volume
and postvoidresidual volume.
27Dept of Urology, GRH and KMC, Chennai.
Uroflowin Men.
Normal uroflowparameters in young men are
well established.
Qmaxgreater than 15 to 20 mL/sec as normal and
less than 10 mL/sec abnormal.
Decline with age by 1 to 2 mL/sec per 5 years.
A maximum flow of 5.5 mL/sec at 80 years
28Dept of Urology, GRH and KMC, Chennai.
Normal uroflowparameters in young men are
well established.
Qmaxgreater than 15 to 20 mL/sec as normal and
less than 10 mL/sec abnormal.
Decline with age by 1 to 2 mL/sec per 5 years.
A maximum flow of 5.5 mL/sec at 80 years
28Dept of Urology, GRH and KMC, Chennai.
Uroflowin Women.
Women have
a very short urethra,
minimal outlet resistance, and
no prostate,
only factors influencing female urofloware
the strength of the detrusormuscle and
the urethral resistance and
the degree of relaxation of the sphincter mechanism.
In the normal woman Qmaxcan be greater than 30 mL/sec,
the flow curve is bell shaped as in men, and
the flow time is shorter
Maximum flow in women does not seem to be dependent
upon age.
29Dept of Urology, GRH and KMC, Chennai.
Women have
a very short urethra,
minimal outlet resistance, and
no prostate,
only factors influencing female urofloware
the strength of the detrusormuscle and
the urethral resistance and
the degree of relaxation of the sphincter mechanism.
In the normal woman Qmaxcan be greater than 30 mL/sec,
the flow curve is bell shaped as in men, and
the flow time is shorter
Maximum flow in women does not seem to be dependent
upon age.
29Dept of Urology, GRH and KMC, Chennai.
The Cystometrogram
Cystometry–
The urodynamicinvestigation of the filling
component of bladder function.
30Dept of Urology, GRH and KMC, Chennai.
Cystometry–
The urodynamicinvestigation of the filling
component of bladder function.
30Dept of Urology, GRH and KMC, Chennai.
The Procedure
Measurement of Intravesicaland Abdominal
Pressure.
Zero pressure is the surrounding atmospheric
pressure.
the reference point is the superior edge of the pubic
symphysis
All systems must be zeroed to atmospheric pressure,
and it is crucial that there are no air bubbles in any of
the transducers or tubing as these may cause pressure
dampening or dissipation.
31Dept of Urology, GRH and KMC, Chennai.
Measurement of Intravesicaland Abdominal
Pressure.
Zero pressure is the surrounding atmospheric
pressure.
the reference point is the superior edge of the pubic
symphysis
All systems must be zeroed to atmospheric pressure,
and it is crucial that there are no air bubbles in any of
the transducers or tubing as these may cause pressure
dampening or dissipation.
31Dept of Urology, GRH and KMC, Chennai.
Fill Medium
A physiologic liquid medium is preferable.
Fluid cystometryuses more physiologic media such as
sterile water, normal saline, or contrast material.
These are not compressible and allow better
assessment of voiding dynamics.
Liquids allow easier detection of incontinence and are
more physiologic.
Other advantages
the ability to determine fluid loss and leak pressures
and
to serve as a medium for fluoroscopy.
32Dept of Urology, GRH and KMC, Chennai.
A physiologic liquid medium is preferable.
Fluid cystometryuses more physiologic media such as
sterile water, normal saline, or contrast material.
These are not compressible and allow better
assessment of voiding dynamics.
Liquids allow easier detection of incontinence and are
more physiologic.
Other advantages
the ability to determine fluid loss and leak pressures
and
to serve as a medium for fluoroscopy.
32Dept of Urology, GRH and KMC, Chennai.
The physical characteristics of the infused liquid
may affect bladder behavior and urodynamic
measurements. Acidic and alkaline solutions may
increase or decrease overactivityin otherwise
normal bladders.
Temperature is also important. eg. Iced water may
provoke overactivity,
33Dept of Urology, GRH and KMC, Chennai.
may affect bladder behavior and urodynamic
measurements. Acidic and alkaline solutions may
increase or decrease overactivityin otherwise
normal bladders.
Temperature is also important. eg. Iced water may
provoke overactivity,
33Dept of Urology, GRH and KMC, Chennai.
FILL RATE
Slow (“physiologic”) fill—less than 10 mL/min
Medium fill—10 to 100 mL/min
Rapid fill—more than 100 mL/min
Filling is most often performed at a medium fill
rate with the slow rates reserved for second fills in
patients who demonstrate significant detrusor
overactivityat a faster fill rate.
Provocative filling using the faster rates may be
used to expose bladder overactivityin patients
with a complaint of urgency.
34Dept of Urology, GRH and KMC, Chennai.
Slow (“physiologic”) fill—less than 10 mL/min
Medium fill—10 to 100 mL/min
Rapid fill—more than 100 mL/min
Filling is most often performed at a medium fill
rate with the slow rates reserved for second fills in
patients who demonstrate significant detrusor
overactivityat a faster fill rate.
Provocative filling using the faster rates may be
used to expose bladder overactivityin patients
with a complaint of urgency.
34Dept of Urology, GRH and KMC, Chennai.
Prior to filling, we prefer to conduct a noninvasive
uroflowtest as described earlier.
The patient is then catheterized for a postvoid
residual at the time of cystometrycatheter
placement.
During cystometry, periodic coughing should be
elicited to ensure accurate pressure recording in
all channels being monitored (Pdetas derived
from Pvesand Pabd).
35Dept of Urology, GRH and KMC, Chennai.
uroflowtest as described earlier.
The patient is then catheterized for a postvoid
residual at the time of cystometrycatheter
placement.
During cystometry, periodic coughing should be
elicited to ensure accurate pressure recording in
all channels being monitored (Pdetas derived
from Pvesand Pabd).
35Dept of Urology, GRH and KMC, Chennai.
A few common errors that result in inability to
obtain a correct zero include
pressure line displacement,
kinking of the tubing,
compression of the lumen of the tubing against
the bladder or rectal wall, and
the presence of air bubbles.
36Dept of Urology, GRH and KMC, Chennai.
obtain a correct zero include
pressure line displacement,
kinking of the tubing,
compression of the lumen of the tubing against
the bladder or rectal wall, and
the presence of air bubbles.
36Dept of Urology, GRH and KMC, Chennai.
Fillingcystometry
During the course of cystometry,
Four bladder characteristics;
capacity, sensation, compliance, and the
occurrence of involuntary contractions.
37Dept of Urology, GRH and KMC, Chennai.
During the course of cystometry,
Four bladder characteristics;
capacity, sensation, compliance, and the
occurrence of involuntary contractions.
37Dept of Urology, GRH and KMC, Chennai.
The typical cystometrogram
(CMG)
(I)The immediate rise to
resting bladder pressure -the
response of the viscoelastic
properties to the stretch of
filling.
(II)The tonus limb-the
viscoelasticproperties of the
bladder wall.
(III)The point at which bladder
wall structures have achieved
maximal elongation and a
pressure rise is caused by
additional filling (i.e., exceeding
the limit of compliance).
(IV)The voiding phase
consisting of a voluntary
bladder contraction
38Dept of Urology, GRH and KMC, Chennai.
(CMG)
(I)The immediate rise to
resting bladder pressure -the
response of the viscoelastic
properties to the stretch of
filling.
(II)The tonus limb-the
viscoelasticproperties of the
bladder wall.
(III)The point at which bladder
wall structures have achieved
maximal elongation and a
pressure rise is caused by
additional filling (i.e., exceeding
the limit of compliance).
(IV)The voiding phase
consisting of a voluntary
bladder contraction
38Dept of Urology, GRH and KMC, Chennai.
The CMG in two components:
the response to filling
when capacity has been achieved,
the period of storage testing when there is no further
fill
patient stresses the full system with provocative
maneuvers such as
cough,
Valsalvamaneuver, and
other provocative activities.
supraphysiologicfilling rates
39Dept of Urology, GRH and KMC, Chennai.
the response to filling
when capacity has been achieved,
the period of storage testing when there is no further
fill
patient stresses the full system with provocative
maneuvers such as
cough,
Valsalvamaneuver, and
other provocative activities.
supraphysiologicfilling rates
39Dept of Urology, GRH and KMC, Chennai.
Capacity
Maximum cystometriccapacity
bladder volume at the end of the filling CMG when
patients have a strong desire to void, feel they can no longer
delay micturition, and are given permission to void . This
volume includes 1.the amount voided and 2.the residual
urine left after the void (postvoidresidual).
The functional bladder capacity is the largest volume voided
as determined by a voiding diary.
The cystometriccapacity is usually slightly greater than
functional bladder capacity
The maximal anesthetic capacity is the volume of the
bladder after filling under anesthesia (general, spinal,
epidural) and is not routinely measured.
40Dept of Urology, GRH and KMC, Chennai.
Maximum cystometriccapacity
bladder volume at the end of the filling CMG when
patients have a strong desire to void, feel they can no longer
delay micturition, and are given permission to void . This
volume includes 1.the amount voided and 2.the residual
urine left after the void (postvoidresidual).
The functional bladder capacity is the largest volume voided
as determined by a voiding diary.
The cystometriccapacity is usually slightly greater than
functional bladder capacity
The maximal anesthetic capacity is the volume of the
bladder after filling under anesthesia (general, spinal,
epidural) and is not routinely measured.
40Dept of Urology, GRH and KMC, Chennai.
Sensation
Bladder sensation is evaluated by questioning the
patient about the feeling of the degree of bladder
fullness and is the point at which cooperation
between the patient and examiner becomes very
important.
Normal bladder sensation -
the first sensation of bladder filling,
the first desire to void, and
a strong desire to void .
Urgency,
pain, and
multiple other sensations should be documented
during filling as well .
41Dept of Urology, GRH and KMC, Chennai.
Bladder sensation is evaluated by questioning the
patient about the feeling of the degree of bladder
fullness and is the point at which cooperation
between the patient and examiner becomes very
important.
Normal bladder sensation -
the first sensation of bladder filling,
the first desire to void, and
a strong desire to void .
Urgency,
pain, and
multiple other sensations should be documented
during filling as well .
41Dept of Urology, GRH and KMC, Chennai.
Compliance
Bladder compliance is the relationship between
change in volume and change in pressure.
It is generally calculated between two points:
the Pdetwith the bladder empty at the start of
filling and
the Pdetat either the maximal cystometric
capacity or the start of a detrusorcontraction.
Normal bladder compliance should be less than
12.5 mL/cm H
2O .
42Dept of Urology, GRH and KMC, Chennai.
Bladder compliance is the relationship between
change in volume and change in pressure.
It is generally calculated between two points:
the Pdetwith the bladder empty at the start of
filling and
the Pdetat either the maximal cystometric
capacity or the start of a detrusorcontraction.
Normal bladder compliance should be less than
12.5 mL/cm H
2O .
42Dept of Urology, GRH and KMC, Chennai.
43Dept of Urology, GRH and KMC, Chennai.
Storage
Normally, bladder filling
occurs with little or no
change in pressure, and
a “stable” bladder is a
reflection of the
integrity of the central
nervous system control
over bladder function.
There should be no
involuntary contractions
during filling
cystometry.
44Dept of Urology, GRH and KMC, Chennai.
Normally, bladder filling
occurs with little or no
change in pressure, and
a “stable” bladder is a
reflection of the
integrity of the central
nervous system control
over bladder function.
There should be no
involuntary contractions
during filling
cystometry.
44Dept of Urology, GRH and KMC, Chennai.
Detrusoroveractivity
Multichannel filling cystometrogramshows detrusor
overactivitywith multiple contractions
45Dept of Urology, GRH and KMC, Chennai.
Multichannel filling cystometrogramshows detrusor
overactivitywith multiple contractions
45Dept of Urology, GRH and KMC, Chennai.
Cystometrysummary
the normal bladder capacity is in the range of 300
to 500 mL;
the bladder should have a constant, low pressure
that usually does not reach more than 6 to 10 cm
H
2O above baseline at the end of filling (end-
filling pressure); and
there should be no involuntary contractions.
46Dept of Urology, GRH and KMC, Chennai.
the normal bladder capacity is in the range of 300
to 500 mL;
the bladder should have a constant, low pressure
that usually does not reach more than 6 to 10 cm
H
2O above baseline at the end of filling (end-
filling pressure); and
there should be no involuntary contractions.
46Dept of Urology, GRH and KMC, Chennai.
Pitfalls in Cystometry
i. pressure measurement artifacts (the presence of air bubbles,
kinked tubing, incorrect placement, migration of the pressure
catheters) and
ii. infusion rate artifacts (especially in neurogenicbladder) and
iii. patient-related issues, including lack of cooperation, outlet
incompetence, and vesicoureteralreflux.
iv. If bladder filling is too rapid,
v. If the bladder outlet is incompetent, urine may leak around the
filling catheter and a low bladder compliance may not be
diagnosed because the bladder is never adequately filled (e.g.,
spinal dysraphism, severe intrinsic sphincter deficiency [ISD] in
an older woman).
47Dept of Urology, GRH and KMC, Chennai.
i. pressure measurement artifacts (the presence of air bubbles,
kinked tubing, incorrect placement, migration of the pressure
catheters) and
ii. infusion rate artifacts (especially in neurogenicbladder) and
iii. patient-related issues, including lack of cooperation, outlet
incompetence, and vesicoureteralreflux.
iv. If bladder filling is too rapid,
v. If the bladder outlet is incompetent, urine may leak around the
filling catheter and a low bladder compliance may not be
diagnosed because the bladder is never adequately filled (e.g.,
spinal dysraphism, severe intrinsic sphincter deficiency [ISD] in
an older woman).
47Dept of Urology, GRH and KMC, Chennai.
Special Testing
Bethanecholsupersensitivitytest
The bethanecholsupersensitivitytestwas described by
Lapidesand modified by Glahn(1970) .
This test involves standard fluid infusion cystometryat a
filling rate of 1 mL/sec until a bladder volume of 100 mLis
achieved.
Bladder pressures are recorded, and
this is repeated two to three times for an average value.
Bethanecholchloride (0.035 mg/kg) then is administered
subcutaneously.
Cystometryis repeated at 10, 20, and 30 minutes after
injection.
48Dept of Urology, GRH and KMC, Chennai.
Bethanecholsupersensitivitytest
The bethanecholsupersensitivitytestwas described by
Lapidesand modified by Glahn(1970) .
This test involves standard fluid infusion cystometryat a
filling rate of 1 mL/sec until a bladder volume of 100 mLis
achieved.
Bladder pressures are recorded, and
this is repeated two to three times for an average value.
Bethanecholchloride (0.035 mg/kg) then is administered
subcutaneously.
Cystometryis repeated at 10, 20, and 30 minutes after
injection.
48Dept of Urology, GRH and KMC, Chennai.
A neurologically intact bladder should have a
pressure increase of less than 15 cm H
2O above the
control value
a “denervated” bladder shows a response greater
than 15 cm H
2O.
A positive test suggests an interruption in the
afferent or efferent peripheral, or distal spinal
innervation, of the bladder.
49Dept of Urology, GRH and KMC, Chennai.
pressure increase of less than 15 cm H
2O above the
control value
a “denervated” bladder shows a response greater
than 15 cm H
2O.
A positive test suggests an interruption in the
afferent or efferent peripheral, or distal spinal
innervation, of the bladder.
49Dept of Urology, GRH and KMC, Chennai.
Ice water test
The ice water testwas first described by Borsand
Blinnas a way to differentiate “upper” from
“lower” motor neuron lesions .
It is based on the principle that mucosal
temperature receptors can elicit a spinal reflex
contraction of the detrusor, a reflex that is
normally inhibited by supraspinalcenters.
50Dept of Urology, GRH and KMC, Chennai.
The ice water testwas first described by Borsand
Blinnas a way to differentiate “upper” from
“lower” motor neuron lesions .
It is based on the principle that mucosal
temperature receptors can elicit a spinal reflex
contraction of the detrusor, a reflex that is
normally inhibited by supraspinalcenters.
50Dept of Urology, GRH and KMC, Chennai.
An upper motor neuron lesion interrupts these
inhibitory pathways, resulting in manifestation of
the reflex
A lower motor neuron lesion does not.
A positive test should therefore theoretically
occur in patients with upper motor neuron
lesions, whereas those with lower motor neuron
lesions and neurologically normal patients
should have a negative test.
51Dept of Urology, GRH and KMC, Chennai.
inhibitory pathways, resulting in manifestation of
the reflex
A lower motor neuron lesion does not.
A positive test should therefore theoretically
occur in patients with upper motor neuron
lesions, whereas those with lower motor neuron
lesions and neurologically normal patients
should have a negative test.
51Dept of Urology, GRH and KMC, Chennai.
The original test involved rapidly injecting the
bladder with ice water;
if the ice water is expelled by the bladder within 1
minute, the test is positive.
The test is positive in approximately 97% of
patients with complete suprasacrallesions and in
91% of those with incomplete suprasacrallesions;
it is almost never positive in patients with lower
motor neuron lesions.
52Dept of Urology, GRH and KMC, Chennai.
bladder with ice water;
if the ice water is expelled by the bladder within 1
minute, the test is positive.
The test is positive in approximately 97% of
patients with complete suprasacrallesions and in
91% of those with incomplete suprasacrallesions;
it is almost never positive in patients with lower
motor neuron lesions.
52Dept of Urology, GRH and KMC, Chennai.
Pressure-Flow Studies
Pressure-flow studies (PFSs) measure the relationship between
pressure in the bladder and urine flow rate during bladder emptying .
Indications :
❖to differentiate between patients with low flow because of
obstruction and those with poor bladder contractility.
❖identify patients with high-pressure obstruction and normal flow
rates .
❖Obstruction
❖1. structural caused by prostatic enlargement and stricture, 2.
functional, caused by proximal or distal sphincter dyssynergia.
❖PFSs alone cannot identify the location of the obstruction, but when
combined with fluoroscopic screening or a sphincter EMG study, the
site of obstruction may be determined.
53Dept of Urology, GRH and KMC, Chennai.
Pressure-flow studies (PFSs) measure the relationship between
pressure in the bladder and urine flow rate during bladder emptying .
Indications :
❖to differentiate between patients with low flow because of
obstruction and those with poor bladder contractility.
❖identify patients with high-pressure obstruction and normal flow
rates .
❖Obstruction
❖1. structural caused by prostatic enlargement and stricture, 2.
functional, caused by proximal or distal sphincter dyssynergia.
❖PFSs alone cannot identify the location of the obstruction, but when
combined with fluoroscopic screening or a sphincter EMG study, the
site of obstruction may be determined.
53Dept of Urology, GRH and KMC, Chennai.
PFSs are especially useful in the evaluation of men with LUTS
A low flow rate is not diagnostic of BOO because 25% to 30% of
patients with low flow rates have detrusorhypocontractility
A normal or high flow rate does not rule out obstruction because 7%
of symptomatic men with a Qmaxgreater than 15 mL/sec have
obstruction
PFSs should be performed when the information obtained will
influence major therapeutic decisions.
Older men with LUTS and any H/O neurologic disease such as CVA,
multiple sclerosis, or Parkinson's disease, which are known to affect
detrusoror sphincter function.
Younger men with LUTS benefit from PFSs to determine whether a
functional disorder (e.g., bladder neck dysfunction) is present.
PFSs are also helpful in men with BPH and Qmaxover 10 mL/sec, a
group making up 30% to 40% of BPH patients.
54Dept of Urology, GRH and KMC, Chennai.
A low flow rate is not diagnostic of BOO because 25% to 30% of
patients with low flow rates have detrusorhypocontractility
A normal or high flow rate does not rule out obstruction because 7%
of symptomatic men with a Qmaxgreater than 15 mL/sec have
obstruction
PFSs should be performed when the information obtained will
influence major therapeutic decisions.
Older men with LUTS and any H/O neurologic disease such as CVA,
multiple sclerosis, or Parkinson's disease, which are known to affect
detrusoror sphincter function.
Younger men with LUTS benefit from PFSs to determine whether a
functional disorder (e.g., bladder neck dysfunction) is present.
PFSs are also helpful in men with BPH and Qmaxover 10 mL/sec, a
group making up 30% to 40% of BPH patients.
54Dept of Urology, GRH and KMC, Chennai.
The normal male generally voids with a Pdetof 40
to 60 cm H
2O, and women typically void with
lower pressures .
Obstruction existed in a patient with a Pdetof 100
cm H
2O at a Qmaxof 10 mL/sec.
55Dept of Urology, GRH and KMC, Chennai.
to 60 cm H
2O, and women typically void with
lower pressures .
Obstruction existed in a patient with a Pdetof 100
cm H
2O at a Qmaxof 10 mL/sec.
55Dept of Urology, GRH and KMC, Chennai.
women with LUTS, depending on the definition,
obstruction was identified in 2.7% to 20% of cases
PFSs may be misleading in women with suspected
obstruction.
56Dept of Urology, GRH and KMC, Chennai.
obstruction was identified in 2.7% to 20% of cases
PFSs may be misleading in women with suspected
obstruction.
56Dept of Urology, GRH and KMC, Chennai.
Female Bladder Outlet Obstruction
Female bladder outlet obstruction is being recognized
more frequently, but standardized urodynamic
criteria for its diagnosis have been lacking.
Blaivasand Groutz(2000) have developed a
nomogramfor the obstructed woman.
urodynamicvalues of maximum flow (Qmax) and
detrusorpressure at maximum flow (Pdet.max),
this nomogramdefines obstruction in women as four
types:
no obstruction,
mild obstruction,
moderate obstruction, and
severe obstruction.
57Dept of Urology, GRH and KMC, Chennai.
Female bladder outlet obstruction is being recognized
more frequently, but standardized urodynamic
criteria for its diagnosis have been lacking.
Blaivasand Groutz(2000) have developed a
nomogramfor the obstructed woman.
urodynamicvalues of maximum flow (Qmax) and
detrusorpressure at maximum flow (Pdet.max),
this nomogramdefines obstruction in women as four
types:
no obstruction,
mild obstruction,
moderate obstruction, and
severe obstruction.
57Dept of Urology, GRH and KMC, Chennai.
Abrams-Griffiths Nomogram.
The Abrams-Griffiths (AG) nomogramwas based
on “theoretical analysis and empirical
observation” in symptomatic men undergoing
PFSs .
Categorized as
Obstructed-> 40 cm H2O
Equivocal-20-40 cm H2O
Unobstructed-< 20 cm H2O.
AG nomogramis calculated from the formula
AG number = PdetQmax-2Qmax .
58Dept of Urology, GRH and KMC, Chennai.
The Abrams-Griffiths (AG) nomogramwas based
on “theoretical analysis and empirical
observation” in symptomatic men undergoing
PFSs .
Categorized as
Obstructed-> 40 cm H2O
Equivocal-20-40 cm H2O
Unobstructed-< 20 cm H2O.
AG nomogramis calculated from the formula
AG number = PdetQmax-2Qmax .
58Dept of Urology, GRH and KMC, Chennai.
for determining urethral resistance is based on
consideration of the urethra as a distensible tube with a
flow-controlling zone, the proximal urethra.
It describes the relationship between pressure and flow
during the period of lowest urethral resistance and
reflects the passive anatomic factors responsible for the
outlet resistance or flow-controlling zone and minimizes
the effect of muscular activity, such as sphincter contraction.
Schafer's method
59Dept of Urology, GRH and KMC, Chennai.
consideration of the urethra as a distensible tube with a
flow-controlling zone, the proximal urethra.
It describes the relationship between pressure and flow
during the period of lowest urethral resistance and
reflects the passive anatomic factors responsible for the
outlet resistance or flow-controlling zone and minimizes
the effect of muscular activity, such as sphincter contraction.
Schafer's method
59Dept of Urology, GRH and KMC, Chennai.
Group-Specific Urethral Resistance
Factor nomogram.
The URA was derived from the recognition of a
correlation between the minimal opening pressure
(Pmuo) and the curvature of the PURR, resulting in
the ability to use one parameter, the URA, to define
obstruction.
A nomogramwas created with a series of parabolic
curves showing the average pressure-flow plots for
different values of Pmuo.
By plotting the PdetQmax*Qmaxpoint from a
patient's PFSs onto the nomogram, a corresponding
URA number is obtained.
A URA greater than 29 cm H
2O is considered to
represent obstruction.
60Dept of Urology, GRH and KMC, Chennai.
Factor nomogram.
The URA was derived from the recognition of a
correlation between the minimal opening pressure
(Pmuo) and the curvature of the PURR, resulting in
the ability to use one parameter, the URA, to define
obstruction.
A nomogramwas created with a series of parabolic
curves showing the average pressure-flow plots for
different values of Pmuo.
By plotting the PdetQmax*Qmaxpoint from a
patient's PFSs onto the nomogram, a corresponding
URA number is obtained.
A URA greater than 29 cm H
2O is considered to
represent obstruction.
60Dept of Urology, GRH and KMC, Chennai.
The ICS Provisional Nomogram
It is very similar to the AG nomogramexcept that the
boundary between unobstructed and equivocal has
been moved to reduce the size of the equivocal region.
A continuous grading of obstruction is possible by
calculating the bladder outlet obstruction index
(BOOI), which is essentially the AG number, given by
the formula
BOOI = PdetQmax-2(Qmax).
The patient is considered
obstructed if the BOOI is greater than 40,
unobstructed if the BOOI is less than 20, and
equivocal if the BOOI is between 20 and 40.
61Dept of Urology, GRH and KMC, Chennai.
It is very similar to the AG nomogramexcept that the
boundary between unobstructed and equivocal has
been moved to reduce the size of the equivocal region.
A continuous grading of obstruction is possible by
calculating the bladder outlet obstruction index
(BOOI), which is essentially the AG number, given by
the formula
BOOI = PdetQmax-2(Qmax).
The patient is considered
obstructed if the BOOI is greater than 40,
unobstructed if the BOOI is less than 20, and
equivocal if the BOOI is between 20 and 40.
61Dept of Urology, GRH and KMC, Chennai.
ICS Provisional Nomogram
62Dept of Urology, GRH and KMC, Chennai.
62Dept of Urology, GRH and KMC, Chennai.
An index of bladder contractility (bladder
contractility index [BCI]) can be factored
PdetQmax+ 5Qmax.
Using this formula for the BCI (i.e., BCI =
PdetQmax+ 5Qmax),
BCI greater than 150 is strong,
BCI less than 100 is weak, and
BCI of 100 to 150 is normal
contractility .
63Dept of Urology, GRH and KMC, Chennai.
contractility index [BCI]) can be factored
PdetQmax+ 5Qmax.
Using this formula for the BCI (i.e., BCI =
PdetQmax+ 5Qmax),
BCI greater than 150 is strong,
BCI less than 100 is weak, and
BCI of 100 to 150 is normal
contractility .
63Dept of Urology, GRH and KMC, Chennai.
If this is plotted graphically on a nomogram,
patients can be categorized into nine classes,
according to three obstruction and three
contractility categories
64Dept of Urology, GRH and KMC, Chennai.
patients can be categorized into nine classes,
according to three obstruction and three
contractility categories
64Dept of Urology, GRH and KMC, Chennai.
Videourodynamics
Def : The simultaneous display of bladder and
urethral pressures with fluoroscopic imaging of the
lower tract is videourodynamics.
It is the most sophisticated form of evaluation of
patients with complex urinary tract dysfunction.
This is desirable when simultaneous evaluation of
structure and function is necessary to make a
diagnosis .
Videourodynamicsis useful to identify the specific
site of the obstruction as being at the bladder neck,
the prostatic urethra, or the distal sphincter
mechanism .
65Dept of Urology, GRH and KMC, Chennai.
Def : The simultaneous display of bladder and
urethral pressures with fluoroscopic imaging of the
lower tract is videourodynamics.
It is the most sophisticated form of evaluation of
patients with complex urinary tract dysfunction.
This is desirable when simultaneous evaluation of
structure and function is necessary to make a
diagnosis .
Videourodynamicsis useful to identify the specific
site of the obstruction as being at the bladder neck,
the prostatic urethra, or the distal sphincter
mechanism .
65Dept of Urology, GRH and KMC, Chennai.
66Dept of Urology, GRH and KMC, Chennai.
A videourodynamicevaluation is indicated when a
diagnosis cannot be made with certainty without
simultaneous evaluation of the structure and
function of the urinary tract ( McGuire et al, 1996a ).
Anatomic abnormalities that can also be identified or
evaluated with videourodynamicsinclude cystocele,
diverticulumof the bladder or urethra, and
abnormalities of the prostatic and proximal urethra,
and it may also give information on the pelvic support
and pelvic organ prolapse.
Significant pelvic organ prolapsemay cause changes
in the urodynamicparameters measured, and the
significance of this cause may go unrecognized unless
fluoroscopy is added.
67Dept of Urology, GRH and KMC, Chennai.
diagnosis cannot be made with certainty without
simultaneous evaluation of the structure and
function of the urinary tract ( McGuire et al, 1996a ).
Anatomic abnormalities that can also be identified or
evaluated with videourodynamicsinclude cystocele,
diverticulumof the bladder or urethra, and
abnormalities of the prostatic and proximal urethra,
and it may also give information on the pelvic support
and pelvic organ prolapse.
Significant pelvic organ prolapsemay cause changes
in the urodynamicparameters measured, and the
significance of this cause may go unrecognized unless
fluoroscopy is added.
67Dept of Urology, GRH and KMC, Chennai.
Videourodynamicstudies can be performed
fluoroscopic units,
a fluoroscopy table, and
a radiographic contrast agent as the filling medium.
A tilting fluoroscopy table is necessary as it allows supine
placement of catheters with easy conversion to a sitting or
standing position to conduct the study.
A commode seat attached to the table facilitates
fluoroscopic screening of voiding in the seated position,
which is ideal for women.
An alternative system, used currently by these authors, uses
a fluoroscopic C-arm and a purpose-made tilting chair
system .
68Dept of Urology, GRH and KMC, Chennai.
fluoroscopic units,
a fluoroscopy table, and
a radiographic contrast agent as the filling medium.
A tilting fluoroscopy table is necessary as it allows supine
placement of catheters with easy conversion to a sitting or
standing position to conduct the study.
A commode seat attached to the table facilitates
fluoroscopic screening of voiding in the seated position,
which is ideal for women.
An alternative system, used currently by these authors, uses
a fluoroscopic C-arm and a purpose-made tilting chair
system .
68Dept of Urology, GRH and KMC, Chennai.
The basic video and urodynamicsetup that allows both
urodynamicand radiologic imaging data to be projected
simultaneously onto a television monitor for real-time
viewing and for digital storage for later review.
Fluoroscopy time is limited by screening only points of
interest (Valsalvaand cough events during fill and sections
of the voiding study) and should be less than 1 minute.
Many manufacturers make urodynamicequipment
integrating the video and pressure flow data.
The most important feature is the capability to measure
urethral and bladder pressures while displaying them
simultaneously with the corresponding fluoroscopic
images ( McGuire et al, 1996a ).
69Dept of Urology, GRH and KMC, Chennai.
urodynamicand radiologic imaging data to be projected
simultaneously onto a television monitor for real-time
viewing and for digital storage for later review.
Fluoroscopy time is limited by screening only points of
interest (Valsalvaand cough events during fill and sections
of the voiding study) and should be less than 1 minute.
Many manufacturers make urodynamicequipment
integrating the video and pressure flow data.
The most important feature is the capability to measure
urethral and bladder pressures while displaying them
simultaneously with the corresponding fluoroscopic
images ( McGuire et al, 1996a ).
69Dept of Urology, GRH and KMC, Chennai.
Using this technique, the examiner is able to gain information on many
aspects of the bladder and bladder function.
Vesicoureteralreflux and the status of the bladder neck and sphincter may
be identified.
The anatomy of the bladder, including diverticula, shape, and bladder
neck, may be determined as well.
Also, it allows identification of dyssynergiaof the proximal and distal
sphincter mechanisms in neurogenicpatients.
70Dept of Urology, GRH and KMC, Chennai.
aspects of the bladder and bladder function.
Vesicoureteralreflux and the status of the bladder neck and sphincter may
be identified.
The anatomy of the bladder, including diverticula, shape, and bladder
neck, may be determined as well.
Also, it allows identification of dyssynergiaof the proximal and distal
sphincter mechanisms in neurogenicpatients.
70Dept of Urology, GRH and KMC, Chennai.
Particular Uses for Videourodynamics
1. Evaluation of Incontinence.
Identify the presence and degree of urethral
hypermobility, bladder neck competence, and the
presence and grade of cystocele.
Video also improves the accuracy of a Valsalva
leak point pressure (VLPP) measurement, making
it is easier to observe the exact moment when
leakage of contrast agent
71Dept of Urology, GRH and KMC, Chennai.
1. Evaluation of Incontinence.
Identify the presence and degree of urethral
hypermobility, bladder neck competence, and the
presence and grade of cystocele.
Video also improves the accuracy of a Valsalva
leak point pressure (VLPP) measurement, making
it is easier to observe the exact moment when
leakage of contrast agent
71Dept of Urology, GRH and KMC, Chennai.
2. Bladder neck dysfunction
incomplete opening of the bladder neck during
urination. This was first fully described by Turner-
Warwick in 1973, most common in young men who
complain of long-standing LUTS ( Webster et al, 1980 ).
Urodynamicsalone can easily show evidence of bladder
outlet obstruction.
The diagnosis of this disorder must be made with real-
time, fluoroscopic imaging of the micturitionevent
showing detrusorcontraction in the absence of bladder
neck relaxation.
72Dept of Urology, GRH and KMC, Chennai.
incomplete opening of the bladder neck during
urination. This was first fully described by Turner-
Warwick in 1973, most common in young men who
complain of long-standing LUTS ( Webster et al, 1980 ).
Urodynamicsalone can easily show evidence of bladder
outlet obstruction.
The diagnosis of this disorder must be made with real-
time, fluoroscopic imaging of the micturitionevent
showing detrusorcontraction in the absence of bladder
neck relaxation.
72Dept of Urology, GRH and KMC, Chennai.
3.Neurogenic Bladder Dysfunction.
For neurogenicdetrusoroveractivity,
simultaneous video screening detects the
presence of leakage per urethra or vesicoureteral
reflux
Aids in the determination of diagnosing proximal
and distal sphincter dyssynergia.
73Dept of Urology, GRH and KMC, Chennai.
For neurogenicdetrusoroveractivity,
simultaneous video screening detects the
presence of leakage per urethra or vesicoureteral
reflux
Aids in the determination of diagnosing proximal
and distal sphincter dyssynergia.
73Dept of Urology, GRH and KMC, Chennai.
Identification of Associated
Pathology.
Videourodynamicsallows the identification and
characterization of a pathologic process that can
be associated with complex voiding dysfunction,
including reflux, diverticula, fistulas, and stones.
74Dept of Urology, GRH and KMC, Chennai.
Pathology.
Videourodynamicsallows the identification and
characterization of a pathologic process that can
be associated with complex voiding dysfunction,
including reflux, diverticula, fistulas, and stones.
74Dept of Urology, GRH and KMC, Chennai.
Multichannel Urodynamics
The use of multichannel urodynamics,
incorporating these components into one all-
inclusive study.
Multichannel urodynamicsuse simultaneous
recording of total bladder pressure (Pves) and
separate abdominal pressure (Pabd).
Detrusorpressure (Pdet) is the component of
intravesicalpressure (Pves) created by both active
(bladder contractions) and passive (elasticity)
forces from the bladder wall .
75Dept of Urology, GRH and KMC, Chennai.
The use of multichannel urodynamics,
incorporating these components into one all-
inclusive study.
Multichannel urodynamicsuse simultaneous
recording of total bladder pressure (Pves) and
separate abdominal pressure (Pabd).
Detrusorpressure (Pdet) is the component of
intravesicalpressure (Pves) created by both active
(bladder contractions) and passive (elasticity)
forces from the bladder wall .
75Dept of Urology, GRH and KMC, Chennai.
The detrusorpressure (Pdet) is derived by
subtracting the Pabdfrom Pves.
Pabdis most often recorded by a catheter placed
in the rectum.
76Dept of Urology, GRH and KMC, Chennai.
subtracting the Pabdfrom Pves.
Pabdis most often recorded by a catheter placed
in the rectum.
76Dept of Urology, GRH and KMC, Chennai.
The pressure transducers for the bladder and rectal
catheters must be at the same reference level (at the
upper edge of the pubic symphysis), and
the rectal catheter should be zeroed to equal bladder
pressure (which is zeroed to atmospheric pressure) at
the start of the study.
The lines should be flushed and the adequacy of
pressure transmission checked by having the patient
cough to demonstrate a rise in rectal pressure (Pabd),
a rise in vesicalpressure (Pves), and essentially no
change in the subtracted detrusorpressure (Pdet).
77Dept of Urology, GRH and KMC, Chennai.
catheters must be at the same reference level (at the
upper edge of the pubic symphysis), and
the rectal catheter should be zeroed to equal bladder
pressure (which is zeroed to atmospheric pressure) at
the start of the study.
The lines should be flushed and the adequacy of
pressure transmission checked by having the patient
cough to demonstrate a rise in rectal pressure (Pabd),
a rise in vesicalpressure (Pves), and essentially no
change in the subtracted detrusorpressure (Pdet).
77Dept of Urology, GRH and KMC, Chennai.
Leak Point Pressures
Two pressures obtained during urodynamics
measure different aspects of lower urinary tract
function, detrusorleak point pressure (DLPP)
and abdominal leak point pressure (ALPP).
DLLP is defined by the ICS as the lowest detrusor
pressure at which urine leakage occurs in the
absence of either a detrusorcontraction or
increased abdominal pressure.
ALPP is the intravesicalpressure at which urine
leakage occurs because of increased abdominal
pressure in the absence of a detrusorcontraction.
78Dept of Urology, GRH and KMC, Chennai.
Two pressures obtained during urodynamics
measure different aspects of lower urinary tract
function, detrusorleak point pressure (DLPP)
and abdominal leak point pressure (ALPP).
DLLP is defined by the ICS as the lowest detrusor
pressure at which urine leakage occurs in the
absence of either a detrusorcontraction or
increased abdominal pressure.
ALPP is the intravesicalpressure at which urine
leakage occurs because of increased abdominal
pressure in the absence of a detrusorcontraction.
78Dept of Urology, GRH and KMC, Chennai.
DetrusorLeak Point Pressure
The DLPP was first introduced by McGuire
An important concept in urodynamicsis the fact that
bladder outlet resistance is the main determinant of
detrusorpressure
If the outlet resistance is high, a higher bladder pressure is
needed to overcome this resistance and cause leakage.
This high pressure can be transmitted to the upper tracts,
causing reflux and hydronephrosis.
McGuire found that in myelodysplasticpatients with an
elevated outlet resistance from a fixed external sphincter,
those with a DLPP greater than 40 cm H
2O were at
significantly higher risk for upper tract deterioration
(hydronephrosis, reflux).
79Dept of Urology, GRH and KMC, Chennai.
The DLPP was first introduced by McGuire
An important concept in urodynamicsis the fact that
bladder outlet resistance is the main determinant of
detrusorpressure
If the outlet resistance is high, a higher bladder pressure is
needed to overcome this resistance and cause leakage.
This high pressure can be transmitted to the upper tracts,
causing reflux and hydronephrosis.
McGuire found that in myelodysplasticpatients with an
elevated outlet resistance from a fixed external sphincter,
those with a DLPP greater than 40 cm H
2O were at
significantly higher risk for upper tract deterioration
(hydronephrosis, reflux).
79Dept of Urology, GRH and KMC, Chennai.
The DLPP is the Pdetrequired to induce leakage
but does not determine what is causing the
elevated DLPP.
The addition of fluoroscopy allows an accurate
method for determining the presence and
location of obstructive uropathy.
80Dept of Urology, GRH and KMC, Chennai.
but does not determine what is causing the
elevated DLPP.
The addition of fluoroscopy allows an accurate
method for determining the presence and
location of obstructive uropathy.
80Dept of Urology, GRH and KMC, Chennai.
Technique for Measurement of
DLPP.
The test is performed during cystometry.
The urethral meatusis observed for leakage while
bladder pressure is measured.
When leakage of urine is noted, the Pdetat that
instant is recorded as the DLPP .
DLPP greater than 40 cm H
2O, there was a
significantly greater risk of
upper tract deterioration.
81Dept of Urology, GRH and KMC, Chennai.
DLPP.
The test is performed during cystometry.
The urethral meatusis observed for leakage while
bladder pressure is measured.
When leakage of urine is noted, the Pdetat that
instant is recorded as the DLPP .
DLPP greater than 40 cm H
2O, there was a
significantly greater risk of
upper tract deterioration.
81Dept of Urology, GRH and KMC, Chennai.
Abdominal Leak Point Pressure
Abdominal pressure does not open a normally
positioned and closed urethral sphincter.
Leakage can be caused only by an increase in
abdominal pressure when the urethra is
abnormal.
This led to the development of the Valsalvaor
abdominal leak point pressure (VLPP, ALPP)
( McGuire et al, 1993 ).
82Dept of Urology, GRH and KMC, Chennai.
Abdominal pressure does not open a normally
positioned and closed urethral sphincter.
Leakage can be caused only by an increase in
abdominal pressure when the urethra is
abnormal.
This led to the development of the Valsalvaor
abdominal leak point pressure (VLPP, ALPP)
( McGuire et al, 1993 ).
82Dept of Urology, GRH and KMC, Chennai.
Testing for ALPP should be done during cystometry
after the bladder has been filled to at least 150 to 200
mL.
The patient is then asked to do a Valsalvamaneuver
until he or she leaks .
The lowest pressure at which incontinence occurs is
the VLPP.
If no leak occurs at measured abdominal pressures of
100 to 140 cm H
2O, the patient is asked to cough until
incontinence occurs.
If there is no leakage with Valsalvaor cough at this
volume, the test is repeated with a volume of 300 mL,
then again at capacity.
83Dept of Urology, GRH and KMC, Chennai.
after the bladder has been filled to at least 150 to 200
mL.
The patient is then asked to do a Valsalvamaneuver
until he or she leaks .
The lowest pressure at which incontinence occurs is
the VLPP.
If no leak occurs at measured abdominal pressures of
100 to 140 cm H
2O, the patient is asked to cough until
incontinence occurs.
If there is no leakage with Valsalvaor cough at this
volume, the test is repeated with a volume of 300 mL,
then again at capacity.
83Dept of Urology, GRH and KMC, Chennai.
84Dept of Urology, GRH and KMC, Chennai.
When there is no leakage at high pressures (>150
cm H
2O), the urethra is unlikely to be the cause of
the patient's incontinence.
85Dept of Urology, GRH and KMC, Chennai.
cm H
2O), the urethra is unlikely to be the cause of
the patient's incontinence.
85Dept of Urology, GRH and KMC, Chennai.
The VLPP or ALPP is reproducible and correlates
well with the grade of symptoms, severity of
incontinence, pad usage, and incontinence
quantification.
A VLPP less than 60 cm H
2O indicates the
presence of significant ISD;
a VLPP of 60 to 90 cm H
2O is equivocal, suggesting
a combination of urethral hypermobilityand
some component of ISD; and
pressures greater than 90 cm H
2O suggest urethral
hypermobilityand minimal ISD.
86Dept of Urology, GRH and KMC, Chennai.
well with the grade of symptoms, severity of
incontinence, pad usage, and incontinence
quantification.
A VLPP less than 60 cm H
2O indicates the
presence of significant ISD;
a VLPP of 60 to 90 cm H
2O is equivocal, suggesting
a combination of urethral hypermobilityand
some component of ISD; and
pressures greater than 90 cm H
2O suggest urethral
hypermobilityand minimal ISD.
86Dept of Urology, GRH and KMC, Chennai.
Urethral Pressure Studies
Two variations of this measurement are
commonly reported:
The static urethral pressure profile (UPP), with its
variants the stress UPP and pressure transmission
ratios, and
The micturitionalUPP.
87Dept of Urology, GRH and KMC, Chennai.
Two variations of this measurement are
commonly reported:
The static urethral pressure profile (UPP), with its
variants the stress UPP and pressure transmission
ratios, and
The micturitionalUPP.
87Dept of Urology, GRH and KMC, Chennai.
Static Urethral Pressure
Profilometry
The urethral pressure is defined by the ICS as the
fluid pressure needed to just open a closed
urethra
The UPP is a graph indicating changes in the
intraluminalpressure along the length of the
urethra.
88Dept of Urology, GRH and KMC, Chennai.
Profilometry
The urethral pressure is defined by the ICS as the
fluid pressure needed to just open a closed
urethra
The UPP is a graph indicating changes in the
intraluminalpressure along the length of the
urethra.
88Dept of Urology, GRH and KMC, Chennai.
The UPP is obtained by recording the intraluminalpressure
changes along the length of the urethra without voiding.
A small (6 to 10 Fr) fluid-filled catheter with circumferentially
positioned side holes is withdrawn from the urethra at a rate of
0.5 cm/sec using a mechanical puller (although withdrawing the
catheter slowly by hand may also be reliable) while the catheter is
perfusedwith liquid at 2 mL/min.
The recorded urethral pressure corresponds to the pressure
needed to keep the urethra open by lifting the wall off the
catheter holes ( Yallaet al, 1980 ; Steele et al, 1998 ).
Ideally, bladder pressure is also measured to nullify the effects of
an associated bladder contraction.
The study may be performed at rest (static UPP) or with
intermittent stress events superimposed (stress UPP).
89Dept of Urology, GRH and KMC, Chennai.
changes along the length of the urethra without voiding.
A small (6 to 10 Fr) fluid-filled catheter with circumferentially
positioned side holes is withdrawn from the urethra at a rate of
0.5 cm/sec using a mechanical puller (although withdrawing the
catheter slowly by hand may also be reliable) while the catheter is
perfusedwith liquid at 2 mL/min.
The recorded urethral pressure corresponds to the pressure
needed to keep the urethra open by lifting the wall off the
catheter holes ( Yallaet al, 1980 ; Steele et al, 1998 ).
Ideally, bladder pressure is also measured to nullify the effects of
an associated bladder contraction.
The study may be performed at rest (static UPP) or with
intermittent stress events superimposed (stress UPP).
89Dept of Urology, GRH and KMC, Chennai.
Stress Urethral Pressure
Profilometry
This is a UPP performed while the patient performs
periodic stress maneuvers (cough) and while
intravesicalpressure is also recorded.
Normally, in women the proximal urethra is
supported intra-abdominally and increases in intra-
abdominal pressure are transmitted to both bladder
and the proximal urethra.
If this is not observed on the stress UPP, the
implication is that the urethra has fallen outside the
intra-abdominal influence (urethral hypermobility)
or the urethra is too rigid or scarred to be influenced
by this extrinsic compression.
90Dept of Urology, GRH and KMC, Chennai.
Profilometry
This is a UPP performed while the patient performs
periodic stress maneuvers (cough) and while
intravesicalpressure is also recorded.
Normally, in women the proximal urethra is
supported intra-abdominally and increases in intra-
abdominal pressure are transmitted to both bladder
and the proximal urethra.
If this is not observed on the stress UPP, the
implication is that the urethra has fallen outside the
intra-abdominal influence (urethral hypermobility)
or the urethra is too rigid or scarred to be influenced
by this extrinsic compression.
90Dept of Urology, GRH and KMC, Chennai.
This study is used to identify the presence and
location of bladder outlet obstruction.
It is performed in a similar fashion to the static UPP
except that the patient voids as the catheter is
withdrawn.
This allows bladder pressure to be compared with
urethral pressure at points along the urethra.
During voiding, bladder pressure should be close to
urethral pressure (isobaric).
If obstruction exists in the urethra, the pressure distal
to the obstruction is low while the bladder pressure,
and the pressure proximal to the obstruction, is high.
Thus, if a significant drop is encountered on catheter
withdrawal, this corresponds to the site of the
obstruction.
MicturitionalUrethral Pressure Profilometry
91Dept of Urology, GRH and KMC, Chennai.
location of bladder outlet obstruction.
It is performed in a similar fashion to the static UPP
except that the patient voids as the catheter is
withdrawn.
This allows bladder pressure to be compared with
urethral pressure at points along the urethra.
During voiding, bladder pressure should be close to
urethral pressure (isobaric).
If obstruction exists in the urethra, the pressure distal
to the obstruction is low while the bladder pressure,
and the pressure proximal to the obstruction, is high.
Thus, if a significant drop is encountered on catheter
withdrawal, this corresponds to the site of the
obstruction.
MicturitionalUrethral Pressure Profilometry
91Dept of Urology, GRH and KMC, Chennai.
AMBULATORY URODYNAMICS
Ambulatory urodynamicmonitoring (AUM) is the
functional testing of the lower urinary tract, utilizing
natural filling and reproducing the patient's everyday
activities
It is a well-established method for investigating lower
urinary tract function while freeing the patient to be
independent and to perform activities that provoke the
urinary symptoms in question.
Its greatest benefit seems to be in patients in whom
conventional urodynamicsis unsuitable or unable to
reproduce the symptoms that are being investigated.
92Dept of Urology, GRH and KMC, Chennai.
Ambulatory urodynamicmonitoring (AUM) is the
functional testing of the lower urinary tract, utilizing
natural filling and reproducing the patient's everyday
activities
It is a well-established method for investigating lower
urinary tract function while freeing the patient to be
independent and to perform activities that provoke the
urinary symptoms in question.
Its greatest benefit seems to be in patients in whom
conventional urodynamicsis unsuitable or unable to
reproduce the symptoms that are being investigated.
92Dept of Urology, GRH and KMC, Chennai.
Guidelines for the performance of AUM
by the ICS
First,
detailed instructions about recording of symptoms,
identification of catheter displacement, and
hardware failure should be given to the patient.
Before the ambulatory investigation,
patients receive an extensive information sheet describing
the test and
the necessary preparation.
They are also provided with a simple diary to record
events,
allowing correlation of the test outcome with symptoms.
The patient is advised to empty the bowel, and urine is
checked for infection.
93Dept of Urology, GRH and KMC, Chennai.
by the ICS
First,
detailed instructions about recording of symptoms,
identification of catheter displacement, and
hardware failure should be given to the patient.
Before the ambulatory investigation,
patients receive an extensive information sheet describing
the test and
the necessary preparation.
They are also provided with a simple diary to record
events,
allowing correlation of the test outcome with symptoms.
The patient is advised to empty the bowel, and urine is
checked for infection.
93Dept of Urology, GRH and KMC, Chennai.
measure intravesicaland abdominal pressures using
fluid-filled lines, microtiptransducers allow greater
mobility.
Catheters are placed and secured firmly and the data
are transmitted to a portable recording device .
Flow measurements can be made using home
uroflowmetrytechniques, and
incontinence can be measured using standard pads .
Initial checks on signal quality by testing of recorded
pressure by coughing and abdominal straining in the
supine, sitting, and erect positions.
Regular cough tests should be carried out by the
patient throughout the study to serve as a quality
check during interpretation.
94Dept of Urology, GRH and KMC, Chennai.
fluid-filled lines, microtiptransducers allow greater
mobility.
Catheters are placed and secured firmly and the data
are transmitted to a portable recording device .
Flow measurements can be made using home
uroflowmetrytechniques, and
incontinence can be measured using standard pads .
Initial checks on signal quality by testing of recorded
pressure by coughing and abdominal straining in the
supine, sitting, and erect positions.
Regular cough tests should be carried out by the
patient throughout the study to serve as a quality
check during interpretation.
94Dept of Urology, GRH and KMC, Chennai.
Disadvantages
lack of minute to minute control on validity of the
signals.
position and fixation of the catheters
dislodgement of the devices.
the diary and data points.
This heavy reliance on patients' compliance may
be a source of significant error
95Dept of Urology, GRH and KMC, Chennai.
lack of minute to minute control on validity of the
signals.
position and fixation of the catheters
dislodgement of the devices.
the diary and data points.
This heavy reliance on patients' compliance may
be a source of significant error
95Dept of Urology, GRH and KMC, Chennai.
Analyses of the AUM tracings are always performed
retrospectively, making them time consuming and labor
intensive.
This should be done by a well-trained specialist ( van Waalwijk
van Doornet al, 2000 ).
The examiner must assess the quality of data recorded by
evaluating several points.
The trace must be carefully examined for activity, which should
have fine second-to-second variation;
the cough tests and other activities that cause abdominal
pressure changes must be regularly present; and
the subtraction must be adequate with minimal change in the
derived detrusorpressure with coughing.
The patient's diary is invaluable to improve the detailed analysis
of events occurring during AUM.
96Dept of Urology, GRH and KMC, Chennai.
retrospectively, making them time consuming and labor
intensive.
This should be done by a well-trained specialist ( van Waalwijk
van Doornet al, 2000 ).
The examiner must assess the quality of data recorded by
evaluating several points.
The trace must be carefully examined for activity, which should
have fine second-to-second variation;
the cough tests and other activities that cause abdominal
pressure changes must be regularly present; and
the subtraction must be adequate with minimal change in the
derived detrusorpressure with coughing.
The patient's diary is invaluable to improve the detailed analysis
of events occurring during AUM.
96Dept of Urology, GRH and KMC, Chennai.
Applications of Ambulatory
UrodynamicMonitoring
Several studies have shown AUM to be more
sensitive for detection of unstable detrusor
contractions, making it helpful when a CMG is
nondiagnostic.
Another use of AUM is in patients with borderline
findings of obstruction and nondiagnosticPFSs.
Studies in both men with chronic retention and
patients with neurogenicbladder have noted that
filling pressures with AUM tend to be significantly
lower than those with a conventional CMG
97Dept of Urology, GRH and KMC, Chennai.
UrodynamicMonitoring
Several studies have shown AUM to be more
sensitive for detection of unstable detrusor
contractions, making it helpful when a CMG is
nondiagnostic.
Another use of AUM is in patients with borderline
findings of obstruction and nondiagnosticPFSs.
Studies in both men with chronic retention and
patients with neurogenicbladder have noted that
filling pressures with AUM tend to be significantly
lower than those with a conventional CMG
97Dept of Urology, GRH and KMC, Chennai.
URODYNAMIC ANALYSIS AND
INTERPRETATION
A good urodynamicstudy is one that is easy to
analyze and would allow any urodynamicistto
come to the same conclusions.
The importance of monitoring the study in real
time in order to obtain the highest quality data
cannot be overemphasized .
Analysis of ambulatory studies will remain
problematic, as it is less easy to conduct real-time
quality assessment.
98Dept of Urology, GRH and KMC, Chennai.
INTERPRETATION
A good urodynamicstudy is one that is easy to
analyze and would allow any urodynamicistto
come to the same conclusions.
The importance of monitoring the study in real
time in order to obtain the highest quality data
cannot be overemphasized .
Analysis of ambulatory studies will remain
problematic, as it is less easy to conduct real-time
quality assessment.
98Dept of Urology, GRH and KMC, Chennai.
The ICS in 2002 also has clearly stated that
“the urodynamictest should be repeated if the
initial test suggests an abnormality, leaves the
cause of troublesome LUTS unresolved, or if there
are technical problems preventing proper analysis.
If a study is inconclusive, one should consider the
consequences of not establishing a clear finding.
For instance, if an invasive therapy such as surgery
is planned, the urodynamicsshould be repeated or
the surgery deferred.”
99Dept of Urology, GRH and KMC, Chennai.
“the urodynamictest should be repeated if the
initial test suggests an abnormality, leaves the
cause of troublesome LUTS unresolved, or if there
are technical problems preventing proper analysis.
If a study is inconclusive, one should consider the
consequences of not establishing a clear finding.
For instance, if an invasive therapy such as surgery
is planned, the urodynamicsshould be repeated or
the surgery deferred.”
99Dept of Urology, GRH and KMC, Chennai.
KEY POINTS
The goal in performing urodynamicsis to answer
specific questions related to the patient's storage and
voiding function.
The simplest and least invasive tests can be used
initially with progression to more sophisticated testing
when the clinical examination and more simple tests
cannot make an accurate diagnosis.
100Dept of Urology, GRH and KMC, Chennai.
The goal in performing urodynamicsis to answer
specific questions related to the patient's storage and
voiding function.
The simplest and least invasive tests can be used
initially with progression to more sophisticated testing
when the clinical examination and more simple tests
cannot make an accurate diagnosis.
100Dept of Urology, GRH and KMC, Chennai.
A well-prepared and counseled patient can contribute
extensively to a good urodynamicstudy.
All urodynamicprocedures should be performed with
a clear indication and a specific question that can be
answered by the study.
Many medications may affect urodynamicoutcomes
and should be stopped with an adequate washout
period prior to the test.
The International Continence Society has also
developed minimum technical specifications for
equipment and conductance of urodynamics.
101Dept of Urology, GRH and KMC, Chennai.
extensively to a good urodynamicstudy.
All urodynamicprocedures should be performed with
a clear indication and a specific question that can be
answered by the study.
Many medications may affect urodynamicoutcomes
and should be stopped with an adequate washout
period prior to the test.
The International Continence Society has also
developed minimum technical specifications for
equipment and conductance of urodynamics.
101Dept of Urology, GRH and KMC, Chennai.
The standard catheter for routine urodynamicsshould
be a transurethral, double-lumen catheter.
Cystometrymust reproduce the patient's normal
clinical status in order to diagnosis and guide therapy.
Patients' understanding and compliance in conducting
the study are absolutely necessary, and a standardized
method must be followed in order to optimize
results.
Cystometryshould evaluate five aspects of bladder
function: sensation, capacity, compliance, stability,
and emptying.
102Dept of Urology, GRH and KMC, Chennai.
be a transurethral, double-lumen catheter.
Cystometrymust reproduce the patient's normal
clinical status in order to diagnosis and guide therapy.
Patients' understanding and compliance in conducting
the study are absolutely necessary, and a standardized
method must be followed in order to optimize
results.
Cystometryshould evaluate five aspects of bladder
function: sensation, capacity, compliance, stability,
and emptying.
102Dept of Urology, GRH and KMC, Chennai.
Videourodynamicsare indicated when a diagnosis
cannot be made with certainty without simultaneous
evaluation of the structure and function of the urinary
tract because they give information on anatomic
abnormalities.
Detrusorpressure is the component of intravesical
pressure created by both active and passive forces from
the bladder wall and is derived by subtracting the Pves
from Pabd(Pdet= Pabd-Pves).
Any urodynamictest should be repeated if the initial
test suggests an abnormality or leaves the cause of
symptoms unresolved and when there are technical
problems preventing proper analysis.
103Dept of Urology, GRH and KMC, Chennai.
cannot be made with certainty without simultaneous
evaluation of the structure and function of the urinary
tract because they give information on anatomic
abnormalities.
Detrusorpressure is the component of intravesical
pressure created by both active and passive forces from
the bladder wall and is derived by subtracting the Pves
from Pabd(Pdet= Pabd-Pves).
Any urodynamictest should be repeated if the initial
test suggests an abnormality or leaves the cause of
symptoms unresolved and when there are technical
problems preventing proper analysis.
103Dept of Urology, GRH and KMC, Chennai.
A VLPP of less than 60 cm H
2O indicates the presence
of significant ISD;
a VLPP of 60 to 90 cm H
2O is equivocal, suggesting a
combination of urethral hypermobilityand some
component of ISD; and
pressures greater than 90 cm H
2O suggest urethral
hypermobilityand minimal ISD.
Several studies have shown AUM to be more sensitive
than a conventional cystometrogramfor detection of
unstable detrusorcontractions, making it helpful when a
CMG is nondiagnostic. 104Dept of Urology, GRH and KMC, Chennai.
2O indicates the presence
of significant ISD;
a VLPP of 60 to 90 cm H
2O is equivocal, suggesting a
combination of urethral hypermobilityand some
component of ISD; and
pressures greater than 90 cm H
2O suggest urethral
hypermobilityand minimal ISD.
Several studies have shown AUM to be more sensitive
than a conventional cystometrogramfor detection of
unstable detrusorcontractions, making it helpful when a
CMG is nondiagnostic. 104Dept of Urology, GRH and KMC, Chennai.
105Dept of Urology, GRH and KMC, Chennai.
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