Urodynamic Study in Lower Urinary Tract Dysfunction

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Urodynamic Study in Lower Urinary Tract
Dysfunction

• Hann-Chorng Kuo
• Department of Urology
• Buddhist Tzu Chi General Hospital

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Lower Urinary Tract Symptoms

• Storage symptoms
• Frequency, Urgency, Nocturia
• Incontinence
• Suprapubic fullness and pain
• Empty symptoms
• Hesitancy, Intermittency, Small caliber,
• Dysuria, Residual urine sensation

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Urinary Incontinence

• Stress incontinence
• Urge incontinence
• Total incontinence
• Overflow incontinence
• Giggle incontinence
• Nocturnal enuresis

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Bladder Diary
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Physical Examination

• Abdominal physical examination
• Bladder, Operation scar
• Perineal examination
• Cystocele, Rectocele, Uterine prolapse
• Urine leakage on cough, fistula
• Vaginal mucosa, Vaginal tenderness
• Neurological examination
• B-C Reflex, PFM contractility, Anal tone

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Laboratory examinations

• Urinalysis urine culture
• Blood chemistry, blood sugar
• KUB
• Uroflowmetry
• Cystoscopy
• Lower urinary tract sonography
• Uroradiology

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Urodynamic study- Lower urinary tract

• Uroflowmetry
• Cystometrography
• External sphincter electromyography
• Pressure flow study
• Videourodynamic study
• Urethral pressure profilometry

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Urodynamic study- Upper urinary tract
Special tests

• Whitaker test (upper tract pressure flow study)
• Ice water test
• Urecholine test
• Rapid cystometrography
• Potassium chloride test
• Other pharmacological test

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Why Urodynamics?

• To obtain information of urinary tract function
  and dysfunction
• To confirm clinical diagnosis
• To compare treatment results
• To investigate pathophysiology of urinary tract
  diseases

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Uroflowmetry Normal flow
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Normal Uroflowmetry

• Qmax gt 15 ml/s in men
• Qmax gt 20 ml/s in women
• Tqmax is lt 1/3 of flow time
• Voided volume 200 500 ml
• A normal flow pattern
• Minimal residual urine (lt 50ml)

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Uroflowmetry Parameters
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Abnormal Flow Pattern

• Very high initial Qmax detrusor instability
  without BOO
• Obstructive flow pattern compressive,constrictive
  flow pattern
• Intermittent and straining pattern
• Saw-teeth flow pattern
• Terminal dribbling pattern

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Uroflowmetry Intermittent flow
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Uroflowmetry Straining flow
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Uroflowmetry Low contractility
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Uroflowmetry Obstructive flow
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Pitfalls of Flow Interpretation

• Qmax is variable between several voids
• 7 of mean with LUTS and high Qmax might have
  bladder outlet obstruction
• Women with detrusor areflexia can have good Qmax
  by abdominal straining
• Embarrassment during examination can greatly
  influence Qmax expression

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Cystometrography

• Measuring intravesical pressure (Pves) during
  bladder filling
• Physiological rate body weight/4 (ml/min)
• Non-physiological filling
• Combined with abdominal pressure (Pabd) and
  external sphincter electromyography (EMG)
• Detrusor pressure (Pdet) Pves- Pabd

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Cystometry - technique
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Cystometrography

• Bladder sensation FSF, FS, US,capacity
• Bladder compliance
• Detrusor pressure at end-filling stage
• Voiding pressure Men lt 50 cmH2O, Women lt35cmH2O
• Coordination of external sphincter EMG

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Normal Cystometrogram

• Resting pressure lt 10 cm water
• FSF at 100-200ml, FS at 300-400 ml
• Cystometric capacity at 400-500 ml
• Voiding pressure lt 50 cm water in men and lt35 cm
  water in women
• A coordinated sphincter EMG activity

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Cystometry- Neurogenic detrusor overactivity and
DESD
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Cystometry- Idiopathic detrusor overactivity
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Cystometry- after contraction
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Bladder sensation

• Increased sensation with rapid filling, cold
  infusion, catheter placement, psychological
• Low detrusor contractility due to smaller bladder
  filling volume
• Vague bladder sensation from peritoneal surface
  in patients with detrusor areflexia
• Patient used abdominal straining to void

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Bladder Compliance

• Compliance is related to filling rate
• Low compliance always combines with low
  contractility and large residuum
• Upper tract deterioration is associated with low
  bladder compliance
• A detrusor leak-point pressure gt40 cm water might
  endanger upper tract

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Poor Bladder Compliance and Stress Urinary
Incontinence
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Detrusor areflexia and Detrusor underactivity

• DA is limited to neuropathy
• Detrusor underactivity low detrusor pressure
  with low flow rate and large residual urine
• DHIC detrusor instability (hyperreflexia) and
  inadequate contractility
• Psychological embarrassment

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Pressure Flow Study

• Measuring detrusor pressure, flow rate, EMG
  activity during voiding phase
• Concomitant recording of intra-abdominal pressure
• Calculation of resistance relation of P Q
• Calculation of Abrams-Griffiths number AG number
  Pdet 2 x Qmax

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Pressure flow study - Technique
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Multi-channel Pressure Flow Study
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Relationship of Pressure Flow
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Pressure flow study DHIC
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Pressure flow studyCystocele and BOO in woman
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Low contractility low flow
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Detrusor overactivity voluntary PFM contraction
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Detrusor overactivity in Storage phase
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Detrusor overactivity in a contracted
bladder
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Provoked DI in storage phase
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Urethral Pressure Profilometry

• Measuring Intra-urethral resistance by perfusion
  technique or microtip transducer
• A static pressure measurement, but cannot
  predicting voiding efficiency
• Dynamic UPP
• Academic purpose and assessment of therapeutic
  results

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Urethral Pressure Profilometry
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Stress UPP in Continent woman
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Stress UPP in Incontinent woman
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Nitric oxide UPP in Neuropathic bladder
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Voluntary Pelvic floor contraction
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Leak-point Pressures

• Measuring the increased intravesical or
  intra-abdominal pressures that cause urine
  leakage per urethrum
• Detrusor LPP pressure causes leakage without
  detrusor contraction or increased intra-abdominal
  pressure
• Abdominal LPP- cough LPP, Valsalva LPP

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Abdominal Leak point pressure in Type I SUI
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Abdominal leak point pressure in Type II SUI
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Cough vs Valsalva LPP in Type II/III SUI
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Cough vs Valsalva LPP in Type II/III SUI
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Cough vs Valsalva LPP in Pure Type III SUI
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LPP Intravesical vs intra-abdominal recording
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Valsalva LPP in Cystocele SUI
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Videourodynamic Study

• Combined image and pressure flow study in
  assessing lower urinary tract dysfunction
• Suprapubic puncture in men
• A lt 6Fr intra-urethral catheter
• Repeat study if the result is equivocal
• Compare free flow rate with the flow expression
  during investigation

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Clinical Application of Videourodynamics in LUTS

• Differential diagnosis of BOO
• Identify types of stress incontinence
• Confirm bladder neck dysfunction and DESD in
  neuropathic voiding dysfunction
• Upper tract dynamics and determine site of
  obstruction
• Analysis of pathophysiology of LUTS

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Videourodynamic study in DI
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Videourodynamic study in Female urethral stricture
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Videourodynamic study in Female urethral stricture
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Mixed DI and SUI
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Poor relaxation of urethral sphincter
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Low pressure and BOO
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Dysfunctional voiding in woman with urge
incontinence
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Videourodynamic study in SUI
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Videourodynamic study in SUI after Pubovaginal
sling
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Videourodynamics in Post-incontinence surgery BOO