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Urodynamic study

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urodynamic study in urology

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Urodynamic study

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