ICS working group published an update on standardised terminology in 2016.

1. REPORTING URODYNAMICS
Dr Mayank Mohan Agarwal
​MS, MRCS(Ed), ​DNB, MCh (PGI, Chd)
​VMMF and IAUA Fellowships Uro-Oncology, Pelvic Floor Reconstruction
(MSKCC, NY; UCLA, LA; WFUBMC, NC)​
Ex-Associate Professor of Urology (PGI, Chd)
Consultant and Head of Urology
Aster Ramesh Cardiac and Multispecialty Hospitals
Guntur (AP), India

2. INTRODUCTION
• Findings in filling phase with physiological correlates
• Findings in voiding phase with physiological correlates
• Reporting pattern for multichannel urodynamics

3. Cystometry - setup
• Fill rate
• Implication – physiological vs supra-physiological
(~10% of FBC on FVC or Weight/4)
• Position of patient
• Sitting / standing / squatting
• Size of catheters
• The smaller the better for bladder (dual lumen vs 2 IFT)
• Type of transducers – water / air-charged / micro-tip
• Results may not be comparable – most standardization on water
transducers
acceptable
Rosier et al. Neurourol Urodynam 2016

4. Cystometry - sensations
• Initial resting pressure
pves and the pabd pressure at the beginning of the cystometry.
• First sensation of filling (FSF)
moment when you perceive that your bladder is not empty anymore
• First desire to void (FDV)
when you have the sensation that normally tells you to go to the toilet, without any
hurry, at the next convenient moment
• Strong desire to void” (SDV)
without any pain or any fear of losing urine, will not postpone the voiding; you will
visit the nearest restroom also, for example, while shopping
• Urgency – for leak / pain
Rosier et al. Neurourol Urodynam 2016

5. Cystometry - sensations
• Initial resting pressure
pves and the pabd pressure at the beginning of the cystometry.
• First sensation of filling (FSF)
moment when you perceive that your bladder is not empty anymore
• First desire to void (FDV)
when you have the sensation that normally tells you to go to the toilet, without any
hurry, at the next convenient moment
• Strong desire to void” (SDV)
without any pain or any fear of losing urine, will not postpone the voiding; you will
visit the nearest restroom also, for example, while shopping
• Urgency – for leak / pain
SENSATIONS (FSF)
0-------100---------200---------
CAPACITY
0-------200---------600---------
COMPLIANCE
0---------10---------20----------50---------
HYPO HYPERNORMAL
LOW HIGHNORMAL
V. LOW NORMALLOW HIGH

6. Cystometry
• Bladder –
 Over-activity
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

7. Cystometry
• Bladder –
 Over-activity
 Compliance
∆V/∆P
In case of reduced compliance – mention flow was
stopped for __min and ___drop of pressure was
observed / not observed
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

8. Cystometry
• Bladder –
 Over-activity
 Compliance
∆V/∆P
• Urethra – ♀ ♂
 Resting profile length 30mm 40-50mm
 MUCP 40-100 40-120cmH2O
Abrams P. Urodynamics 2006

9. Cystometry
• Bladder –
 Over-activity
 Compliance
∆V/∆P
• Urethra –
 Resting profile
 MUCP
• EMG –
 Guarding reflex
URETHRA
BLADDER
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

10. Cystometry
• Bladder –
 Over-activity
 Compliance
∆V/∆P
• Urethra –
 Resting profile
 MUCP
• EMG –
 Guarding reflex
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

11. Cystometry – leak point pressure
• No standard method – report as it was done
• Abdominal LPP (Urodynamic stress test)
• The provocation method (cough/Valsalva)
• Bladder Volume
• Detrusor LPP
• Detrusor overactivity (DO)
• DO associated leak
• Cough associated detrusor overactivity
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

12. Cystometry – leak point pressure
• No standard method – report as it was done
• Abdominal LPP (Urodynamic stress test)
• The provocation method (cough/Valsalva)
• Bladder Volume
• Detrusor LPP
• Detrusor overactivity (DO)
• DO associated leak
• Cough associated detrusor overactivity
ALPP
0-------60------------90---------
LOW HIGHborderline
DLPP
0---------40---------
SAFE UNSAFE

13. Pressure-flow study: BNO / prostatic obstruction
-
-
+
- +
+
++
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

14. BNO/BPO
• Bladder –
 Pdet
 Qmax
 PVR
 Bell-shaped curve
Pdetmax 72
PdetQmax 62
Qmax 8
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

15. BNO/BPO
• Bladder –
 Pdet
 Qmax
 PVR
 Bell shaped curve
• Urethra –
 Pressure gradient
 Starting point
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014, Jain et al. Urology 2014

16. • Bladder –
 Pdet
 Qmax
 PVR
• Urethra –
 Pressure gradient
 Starting point
• EMG –
 Relaxation
Batavia et al. J Urol 2011

17. • Bladder –
 Pdet
 Qmax
 PVR
• Urethra –
 Pressure gradient
 Starting point
• EMG –
 Relaxation
• Pressure-flow relations –
Agarwal MM. Manual of urodynamics. 2014

18. Pressure-flow study: EUSD with DUA
-
-
+
- +
-
+ -

19. EUSD
• Plateau pattern
• Flow starts at Pdetmax
• PdetQmax ≈ Pdetmax
Agarwal et al. Ind J Urol 2016

20. EUSD
• Plateau pattern
• Flow starts at Pdexmax
• PdetQmax ≈ Pdetmax
Agarwal et al. Ind J Urol 2016

21. EUSD
• Plateau pattern
• Flow starts at Pdexmax
• PdetQmax ≈ Pdetmax
• Pura gradient at EUS
Jain et al. Urology 2014

22. EUSD
• Plateau pattern
• Flow starts at Pdexmax
• PdetQmax ≈ Pdetmax
• Pura gradient at EUS
• EMG –
• Relaxation with intermittent spikes
Batavia et al. J Urol 2011

23. EUSD
• Plateau pattern
• Flow starts at Pdexmax
• PdetQmax ≈ Pdetmax
• Pura gradient at EUS
• EMG –
• Increased activity
Batavia et al. J Urol 2011

24. Voiding phase: DUA without EUSD

25. Pressure-flow study
• Position of patient
• pressure-flow analysis is only validated for voluntarily initiated micturitions
and not for incontinence
Rosier et al. Neurourol Urodynam 2016

26. Pressure-flow study
• Position of patient
• pressure-flow analysis is only validated for voluntarily initiated micturitions
and not for incontinence
• Comment on type of pressure-flow relation -
Normal voiding function: flow rate (and pressure-rise) are within normal
limits, begin more or less directly after permission to void and ends with an
empty bladder.
Rosier et al. Neurourol Urodynam 2016

27. Pressure-flow study
• Position of patient
• pressure-flow analysis is only validated for voluntarily initiated micturitions
and not for incontinence
• Comment on type of pressure-flow relation -
Bladder Outflow Obstruction (BOO): ‘high pressure – low flow’ type
relation, with / without hesitancy, with / without PVR [needs help from plots,
formulae, clinical correlation]
Rosier et al. Neurourol Urodynam 2016

28. Pressure-flow study
• Position of patient
• pressure-flow analysis is only validated for voluntarily initiated micturitions
and not for incontinence
• Comment on type of pressure-flow relation
Detrusor underactivity (DUA): ‘low pressure – low flow’ relation,
unsustained contraction or fading contraction with / without elevated PVR
[needs help from plots, formulae, clinical correlation]
Rosier et al. Neurourol Urodynam 2016

29. Pressure-flow study
• Position of patient
• pressure-flow analysis is only validated for voluntarily initiated micturitions
and not for incontinence
• Comment on type of pressure-flow relation
“Situational inability to void” / “Situational inability to void as usual”
when in the opinion of the person performing the test, in communication with the patient, the
attempted voiding has been not representative.
Rosier et al. Neurourol Urodynam 2016

30. Graph and plot
• “ICS standard urodynamic (time-based) graph”
• “ICS standard pressure-flow plot”
Rosier et al. Neurourol Urodynam 2016

31. Graph and plot
• “ICS standard urodynamic (time-based) graph”
• “ICS standard pressure-flow plot”

32. Graph and plot
• “ICS standard urodynamic (time-based) graph”
• “ICS standard pressure-flow plot”

33. Graph and plot
• “ICS standard urodynamic (time-based) graph”
• “ICS standard pressure-flow plot”
BOOI (pdetQmx –[2xQmx])
0--------20--------40--------
DCI (pdetQmx + [5xQmx])
0---------50---------100----------150-----
VOIDING EFFICIENCY
(%VV/[VV+PVR])
0----------70----------100
UNOBS. OBS.BORDERL.
V. WEAK NORMALWEAK STRONG
ABNORMAL ACCEPTABLE

34. CONCLUSION

35. THANK YOU