Basic Intro to Urodynaimcs

1. The Bladder is an Unreliable
Witness
Dr. Roshan V Shetty
Senior Resident- I
Department Of Urology
AJIMS&HRC
Mangaluru

2. • Previously, clinicians chose to assess the lower
urinary tract using “static” investigations, such
as intravenous pyelography (IVP) and
cystourethroscopy.
• However, the lower urinary tract, both during
filling and emptying, is a dynamic system and
hence needs a Dynamic Investigation.

3. • Physiology
• LUTS
• Physical Examination and Laboratory Tests
• Urodynamic Testing: When and Which
• Voiding Diary and Pad Testing
• Noninvasive Urodynamics
• Invasive Urodynamics
• Electromyography of Pelvic Floor Muscles
• Urethral Profilometry
• Videourodynamics (VUDS)
• Ambulatory Urodynamics
• Urodynamics of the Upper Urinary Tract

6. • The key symptoms of lower urinary tract are
divided according to micturition cycle in:
• Storage symptoms
• Voiding symptoms

7. Storage Symptoms
• Increased daytime frequency
• Urgency
• Nocturia
• Urinary incontinence
• Nocturnal enuresis in children
• Painful bladder

8. Increased daytime frequency
• Increased daytime frequency is the need to void
too often by day.
• The normal diurnal frequency is between 3-7 x
day.
• Frequency can occur as a result of reduced FBC
or incomplete bladder emptying or both.
• The assessment of FBC through a voiding diary
is the first step in the evaluation of symptom.

9. Increased daytime frequency

10. Urgency
• Urgency is the complaint of a sudden, compelling
desire to void which is difficult to defer.
• Urgency is the distinctive feature of overactive
bladder (OAB)
• Three key components in what the patient
perceives as urinary urgency:
– Peripheral factors that generate the sensation of urgency
– The processes by which the sensation is transmitted to
the brain (A-delta myelinated fibers or C fibers)
– The manner in which the brain interprets and controls
the sensation.

12. • Filling cystometry is the most suitable
urodynamic test to assess urgency.
• Three findings can be observed:
• Phasic detrusor overactivity
• Terminal detrusor overactivity
• Hypersensitive bladder

13. Urgency

14. Nocturia
• Nocturia is the complaint of interruption of sleep
one or more times because of the need to
micturate.
• Each void is preceded and followed by sleep.
• Nocturia can be related to four distinct
mechanisms:
– Global polyuria (>40ml/kg)
– Nocturnal polyuria ( NUV> 1/3 of 24 Hr UV)
– Reduced bladder capacity (NBC)
– Sleep disorder (Low arousal threshold)

16. Nocturia

17. Urinary incontinence
• Urinary incontinence is the complaint of any
involuntary leakage of urine.
• There are three main types of incontinence:
1. Stress incontinence
2. Urge incontinence
3. Mixed incontinence

18. Stress Incontinence
• Stress incontinence is the complaint of
involuntary loss of urine on effort or physical
exertion
• “Activity related incontinence”
• In female , there are two mechanisms underlying
the disorder:
– Defect in the urethral support for a weakening of the
muscles of the floor pelvic or ligament injury support
(hypermobility of the urethra).
– Lack of urethral tone (intrinsic sphincter deficiency).
• In most of the women, the mechanisms coexist.

19. • According to ACOG guidelines, the minimum
evaluation to distinguish between uncomplicated
and complicated SUI includes:
History
Urinalysis
Physical examination
Demonstration of stress incontinence
Assessment of urethral mobility
Measurement of post-void residual urine

20. • The history should include questions about
– type of incontinence (e.g., stress, urge, mixed)
– precipitating events,
– frequency of occurrence,
– severity
– pad use
– effect of symptoms on activities of daily living.
• Urinalysis
Urinary tract infection should be ruled out
through urinalysis and urine culture.

21. • Physical Examination
– POP- Beyond hymen- Uncomplicated SUI
• Demonstration of Stress Incontinence: Cough
Stress Test
– Present - Uncomplicated SUI
– Delayed or absent – Complicated SUI
• Assessment of Urethral Mobility
– Qtip > 30°- Hypermobility – UnC SUI

22. • Post-void Residual Urine
– >150 ml can indicate a bladder-emptying
abnormality due to a mechanical obstruction
secondary to POP.
– An elevated PVRU in the absence of POP is
uncommon and should trigger an evaluation of
the bladder-emptying mechanism.

23. Stress Urinary incontinence
Females

24. Stress Urinary incontinence
in Males
• Male stress incontinence is a common problem in subjects
who have been treated for Prostate cancer.
• The symptom is typically caused by a damage of the
external sphincter.
• Less commonly it can be due to a detrusor dysfunction or
to an obstruction resulting from an anastomotic stricture.
• Return of continence within 6 months–1 year after surgery.
• Pelvic floor muscle exercises are recommended, clinical
evaluation should be limited to voiding diary and pad
testing to supervise the functional bladder capacity and the
progress in the severity of incontinence.
• A PVRU by ultrasound may be useful to exclude a stricture
of the anastomosis.

26. Nocturnal enuresis
NE: It is the complaint of loss of urine occurring
during sleep.
– Primary: No prior period of sustained dryness
– Secondary: Recurrence of nighttime wetting after
6 months or longer of dryness.
– Monosymptomatic: Normal void occurring at
night in bed in the absence of any other
symptoms referable to the urogenital tract.
– Polysymptomatic: Bed-wetting associated with
other bladder symptoms such as urgency.

27. Sequence
• Bowel control during sleep
• Bowel control when awake
• Dry in the day
• Dry at night after a variable interval from being dry during
the day.
• Diagnosis of nocturnal enuresis to be established,
– Child 5–6 years old should have two or more bed-wetting
episodes per month, and a
– Child older than 6 years of age should have one or more wetting
episode per month.

28. • Three basic mechanisms
– Nocturnal polyuria as a result of low nocturnal
vasopressin levels
– Bladder overactivity/low voided volume
– Lack of arousal from sleep.

29. Nocturnal enuresis in children
Overactive bladder
Dysfunctional voiding
Underactive bladder

30. Painful bladder
• Painful bladder is the complaint of recurring
discomfort or pain in the bladder and the
surrounding pelvic region.
• Symptoms: Urgency, Frequency, Pain with
changing intensity as bladder fills or empties.
• Assessment should rule out other treatable
conditions before considering a diagnosis of
painful bladder
• UTI, Bladder Neoplasm, Chronic prostatitis,
Endometriosis

31. • Urinalysis and urine culture
• Cytology and (when indicated) cystoscopy
• Filling Cystometery
Volume @FD, ND, SD and Max Cystometric
capacity in the absence of detrusor overactvity

32. Painful bladder

33. Voiding Symptoms
• Hesitancy
• Straining
• Position-dependent micturition
• Slow stream
• Intermittent stream
• Terminal dribble
• Dysuria
• Stranguria
• Double Voiding
All these complaints have
as a common final
outcome the
poor emptying of the
bladder.

34. Voiding symptoms in adult men may depend on
three causes:
• Obstruction (more common)
• Detrusor hypocontractility (still poorly defined)
• Poor relaxation of the external sphincter (also
called dysfunctional voiding)

35. • Free flowmetry is the best screening test.
• However, in cases of doubt and always before
surgery or other invasive procedures, a
pressure/flow study is strongly recommended.
• There was no consensus whether PFS should or
may be performed when considering surgery in
men with bothersome predominantly voiding
LUTS and Qmax > 10 mL/s.

36. >10ml/sec

37. Voiding symptoms in women may depend on
four causes:
• Prolapse of 3rd–4th grade that compresses the
urethra
• After anti-incontinence surgery
• Dysfunctional voiding (urethral syndrome)
• Detrusor hypocontractility

38. Qmax <12 ml/s and Pdet
at Q max <20 cm H2O

39. Physical Examination and Laboratory
Tests
• Abdominal Palpation
• Vaginal Examination
– POP-Q
– Q-Tip Test
• Pelvic Floor Muscle (PFM) Testing
• Rectal Examination
• Focused Neurological Examination
• Laboratory Evaluation

41. Laboratory evaluation should include:
• Checking for urinary tract infection
• Cytology to exclude urinary tract malignancy
• Biochemical tests for renal function

42. Urodynamic Testing: When
and Which
• When Is Urodynamic Testing Indicated?
• Urodynamics may be optional or even
unnecessary when:
- A conservative treatment is planned.
- In patients with uncomplicated SUI
- In patients with neurogenic bladder at low risk of renal
complications (multiple sclerosis).

43. • Urodynamics is useful when:
– The patient’s symptoms do not correlate with objective
findings (complex symptoms).
– Prior therapies have failed.
• Urodynamics is strongly recommended:
– In females with UI or POP when an invasive procedure is
planned
– In men with voiding symptoms to assess if symptoms are
due to BOO or detrusor underactivity when TURP is
planned
– In patients with neurogenic bladder who will require long
term urologic management, to establish a baseline.

44. • Which Testing Should Be Selected?
Urodynamics
testing
Non-invasive
evaluation
Invasive
evaluation
Conventional
urodynamics
Ambulatory
urodynamic

46. Voiding Diary and Pad
Testing
Voiding Diary
• The important parameters recorded in a voiding
diary include:
– Urinary frequency during day and night
– Functional bladder capacity (i.e., the average volume
recorded)
– Nocturnal urine output and diurnal urine output
– Number of leakage episodes
– The degree of urgency
– The volume of liquid drunk

48. • The voiding diary has multiple advantages:
– It is an inexpensive test.
– It is a practical substitute for cystometry and, in
some way, is even better since the average voided
volume on voiding diary is more physiological than
patient’s cystometric capacity.
– It is a useful tool to evaluate the effect of therapy.

49. • Pad Testing for incontinence
– 1-h Pad Test
• Positive 1-h pad test is urine loss greater than 1.4 g.
– 24-h Pad Test
• Positive 24-h pad test is a loss greater than 8 g.

50. Noninvasive Urodynamic
• Uroflowmetry
• Definition
– Flow is defined by the fluid expelled from the
urethra per unit of time.
• The aim is to recreate a patient’s natural
voiding pattern.

51. Flow rate (Q): Volume of fluid expelled via the urethra per unit time
(ml/s)
Voided volume (Vvoid): Total volume expelled via the urethra(ml)
Maximum flow rate (Qmax): Maximum measured value of the flow
rate after correction for artifacts
Voiding time: Total duration of micturition (s)
Flow time: Time over which measurable flow actually occurs
Average flow rate (Qave): Voided volume divided by the flow time
Time to maximum flow: Elapsed time from onset of flow to
maximum flow

52. Normal: It is a bell-shaped curve with
Qmax reached in the
initial one third of the void (usually 3–10 s)
BPH: Pattern of flow seems
normal til Qmax (lower than
normal) with a terminal
prolongation. Average flow is
typically lower than normal.
“Constrictive” obstruction, e.g.,
urethral stricture: A low
Qmax is rapidly reached, and the
flow rate remains relatively
constant, giving to the curve a
plateau-shaped
appearance.
“Staccato” curve, e.g., dysfunctional
voiding: Fluctuations
in the flow curve due to burst of
involuntary external
sphincter contractions during
voiding.
Intermittent flow, e.g., abdominal
straining or neuropathic
sphincter dyssynergia: A flow that
stops and starts
several times during voiding
Morphology of the
curve

53. Numerical Parameters
• In males with no bladder outlet obstruction, the
value of
• Qmax tends to decrease with age:
– Under 40 years the value is usually over 25 ml/s.
– Over 60 years the value should be over 15 ml/s.
• In females flow rate is higher than in males
• 5–10 ml/s higher due to the simplified anatomy
of the female urethra.

54. • Flow Nomograms

55. Artefacts

56. Advantages and Disadvantages of
Uroflowmetry
• Uroflowmetry is an excellent non-invasive
screening test.
• Uroflowmetry is unable to discriminate
between an obstruction and a detrusor
hypocontractility.
• It can be used as a measure of progression of
the disease or its response to treatment.

57. Post-void Residual Urine (PVR)
• Post-void residual urine is defined as the
volume of urine left in the bladder at the end
of micturition
• Invasively /Noninvasively
• Values greater than 150 ml are to be
considered pathological and require a USG of
the upper urinary tract to exclude a dilatation

58. New Noninvasive Urodynamic
Techniques
• Bladder/Detrusor Wall Thickness (DWT)
– The measurement should be done with at least
250 ml of urine in the bladder
– measurement is done at the dome
– >2-4 mm significant

59. • Penile Cuff Compression Techniques
– The principle of these tests is to
interrupt the flow at its maximum
value and measure the bladder
isovolumetric pressure which
theoretically correlates with
detrusor performance.
– Overestimates bladder pressure by
+/-14cm H2O.

61. Bipolar

62. Biorad storz compatible