URODYNAMICS

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

INTRODUCTION
Dynamic study of the transport, storage,
and evacuation of urine.
Series of tests to gain information about
urine storage and evacuation
3

HOW TO START
UDE?
4

THREE IMPORTANT RULES BEFOR UDE…
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.
5

THREE CRITICAL“GOOD URODYNAMIC PRACTICE ELEMENTS”
Have a clear indication
for, and appropriate
selection of, relevant
test measurements and
procedures.
01
Ensure precise
measurement with data
quality control and
complete
documentation.
02
Accurately analyze and
critically report results.
This includes interpreting
UDS in the context of a
patient ’ s history and
symptoms.
03
6

WHY UDE???
To diagnose the underlying cause of lower urinary tract dysfunction
To characterize the lower urinary tract dysfunction
To Formulate treatment strategies
To Improve therapeutic outcomes
To Educate patients regarding their condition
7

AIM
 Reproduce the troublesome symptoms
 Answer specific clinical questions
 Establish a precise diagnosis
 Determine the severity of the condition
 Plan further investigations or therapies
Urologist’sStethoscope 8

THINGS TO DO BEFORE PROCEEDING TO UDE…
Proper Clinical History
Voiding diary
Urine culture – Exclude UTI
Physical Examination
• Local & systemic examination
• Neurological evaluation – Integrity of sacral arc
9

COMPONENTS
Uroflowmetry
Postvoid residual (PVR) urine volume
Cystometrogram
Pressure Flow studies of voiding
Electromyogram
Urethral pressure profilometry
Videourodynamics
10

UROFLOWMETRY
 Simplest and often most useful
 Non invasive & inexpensive
 Normal - if the patient voids at least 200 mL over 15 to 20
s, and it is recorded as a smooth single curve with a
maximum flow rate greater than 20 mL/sec
 Voided volume should be between 150 – 400 ml
11

NORMAL
FLOW
PATTERN
12

COMPRESSIVE OBSTRUCTION
 Pattern of flow seems normal til Qmax
(lower than normal) with a terminal
prolongation.
 Average flow is typically lower than
normal.
 BPH
13

OUTFLOW OBSTRUCTION
14

CONSTRICTIVE OBSTRUCTION
 A low Qmax is rapidly reached, and
the flow rate remains relatively
constant, giving to the curve a plateau-
shaped appearance
 Urethral Stricture
15

URETHRAL STRICTURE
16

STACCATO CURVE
 Fluctuations in the flow curve due to
burst of involuntary external sphincter
contractions during voiding.
 Dysfunctional voiding
17

INTERMITTENT FLOW
 A flow that stops and starts several
times during voiding
 Abdominal straining or neuropathic
sphincter dyssynergia
18

SUPERVOIDER / FAST BLADDER
 Very high Qmax with very rapid
upstroke and downstroke.
 Not diagnostic, but people (mostly
females) with detrusor overactivity or
stress urinary incontinence may have a
flow rate at the top of the range
19

POSTVOID RESIDUAL URINE
 Up to 25 ml & PVR less than 10% of the total
bladder volume - normal
 Between 50 and 100 ml - interpreted in the clinical
context
 Values greater than 150 ml - pathological
20

MULTICHANNEL URODYNAMICS
21

MULTICHANNEL
URODYNAMICS
22

URODYNAMIC SETUP
23

PRESSURE/FLOW WORK STATION
 A - Transducers on adjustable height
stand
 B - Pump for bladder filling
 C – Display with superimposed
screening image in videourodynamics
 D - uroflowmeter
B
A
C
D
24

VIDEOURODYNAMICS
25

LAYOUT OF GRAPHICAL DISPLAY - ICS
 Intra-abdominal pressure (Pabd) is
displayed at the top
 Intra-vesical pressure (Pves) next
 Subtracted detrusor pressure (Pdet) next
((Pdet = Pves − Pabd))
 Urinary flow rate (Q) is displayed at the
bottom
 Infused volume, voided volume, urethral
pressure, EMG traces and video screening
images can be displayed optionally.
Uroflowmetry 26

SETUP OF THE
PATIENT
27

STEP 1
 Step 1: EMG electrode placement
 Position the electrodes on the skin around the
patient anus and on the thigh to act as the ground
lead
28

STEP 2
 Step 2: Sterilizing the urethra
29

STEP 3
 Step 3: Post-void residual urine
measurement
 Drain the bladder with a catheter to
obtain a post-void residual urine
measurement.
30

STEP 4
 Step 4: Catheter insertion into the bladder
and rectum
 In female advance the catheter into the
bladder 8 – 10cm
 In males, do not advance it more than 24
centimeters.
 For rectal placement - to a depth of
approximately 10-15cm
 Once inserted, each catheter should be
securely fixed and then connected to its
respective cable. 31

STEP 5
 Step 5: Flushing
 Free the catheters of air inside the channel by
flushing with infusion fluid
32

STEP 6
 Step 6: Zeroing UDS machine
 Atmospheric pressure taken as zero
 Reference height - Superior border of the symphysis
pubis – Transducers placed at this level
 The syringe and catheter connection is blocked, while
the 3-way taps of the transducers are opened to
atmospheric pressure and the “zero all” button is
pressed.
 By this way, all the three lines Pves, Pabd, and Pdet
show “zero” reading. 33

34

POSITION OF EXTERNAL FLUID FILLED
TRANSDUCERS
Set at the level of the pubic symphysis to
allow standardization and comparison.
Increasing the height of the external
transducer lowers the measured pressure
Lowering the height increases the
measured pressure.
The position of the catheter in the organ
has no effect on the measured pressure.
35

POSITION OF MICROTIPTRANSDUCER / AIR
FILLED BALLOON
The position of the internal transducer or
balloon within the bladder alters the
measured pressure.
If the position is lower, then a higher pressure
will be measured due to the extra fluid
column above the transducer/balloon
High position will therefore have a lower
pressure
36

BASELINE PRESSURE CHECK
Pdet should show a near-zero value (<6 cmH 2 O) since
Pves and Pabd are equal and detrusor activity is absent
with
bladder empty
37

RESTING DETRUSOR PRESSURE
If the Pdet is too high (>6 cm H2O) or negative
CHECKTHE POSITION OF
RECTAL ANDVESICAL
CATHETER
EXCLUDE KINKS AND LEAKS
FLUSHTHE SYSTEMTO REMOVE
ANYAIR BUBBLES
Due to the pressure subtraction the Pdet should be <6 cm
H2O and ideally as close to zero as possible.
38

STEP 7
 Step 7: Checking the quality of signals
 Checked by asking the patient to gently
cough.
 Both Pabd and Pves respond equally with
a rapid peak and rapid drop and the
detrusor line should be unaffected.
 A small biphasic deflection is normal, but
any rise or fall in the detrusor pressure
during cough suggests a dampening in the
vesical or abdominal system.
39

DAMPENING EFFECT
Air bubble being compressed and ‘absorbing’ some of the pressure wave leading to
reduced transmission and a lower baseline and lower deflection on the trace.
40

QUALITY
CHECK &
EFFECT OF
DAMPENING
41

FILLING &VOIDING
CYSTOMETRY
42

9 Cs of PRESSURE FLOW STUDIES
STORAGE PHASE – 5 Cs
 Contractions (involuntary
detrusor)
 Compliance
 Coarse sensation
 Continence
 Cystometric capacity
VOIDING PHASE – 4 Cs
 Contractility
 Complete emptying
 Coordination (Detrusor
sphincter)
 Clinical obstruction
43

NORMAL
STORAGE
REFLEX
44

NORMAL
MICTURITION
REFLEX
45

TWO PHASES OF CYSTOMETRY
 Storage/filling phase (also termed as FILLING CYSTOMETRY):
 Commences when the pump is turned on
 Ends when the patient and the urodynamacist decide that ‘permission to void’ has been
given (usually at maximum tolerated capacity).
 Voiding phase (also termed asVOIDING CYSTOMETRY):
 Commences when the patient and the urodynamicist decide that ‘permission to void’ has
been given, or when uncontrollable voiding begins
 Ends when the patient considers that voiding has finished.
46

4 PHASES OF CYSTOMETRIC BLADDER FUNCTION
1. Initial small increase in intravesical
pressure at the beginning of filling
2. Stable pressure that comprises the
majority of the filling phase
3. Terminal pressure rise at bladder
capacity, representing the limit of
viscoelastic expansion (often not
reached due to discomfort)
4. Voiding phase with an inconsistently
observed small increase in intravesical
pressure
47

FILL RATE
The rate of filling should have been decided prior to
beginning the procedure.
• Slow fill: <10 ml/min – a more ‘physiological’ filling rate, used in
neurogenic patients.
• Medium fill: 10–100 ml/min – the most frequent fi lling rate.
• Rapid fill: >100 ml/min – a very rapid provocative fi lling rate.
The ICS originally categorised this into three fill rates:
48

STORAGE PHASE MEASURES
 BLADDER SENSATION
 BLADDER COMPLIANCE
 DETRUSOR FUNCTION
 CYSTOMETRIC BLADDER CAPACITY
 URETHRAL FUNCTION DURING STORAGE PHASE
 ABDOMINAL LEAK POINT PRESSURE
 DETRUSOR LEAK POINT PRESSURE
49

1. BLADDER SENSATION
50

NORMAL SENSATION
First sensation of bladder filling – 170 – 200 mL or
~ 50% of Maximum cystometric capacity (MCC)
First desire to void ~ 250mL or ~75% of MCC
Strong desire to void ~ 400 or ~90% of MCC
51

BLADDER SENSATION
Increased – an early first sensation or an early
desire to void and/or an early strong desire to
void, which occurs at a low bladder volume and
which persists
Reduced – diminished sensation throughout
bladder filling
52

DETRUSOR
HYPERSENSITIVITY
Strong desire to void occurring at low filling volume without any
detrusor contraction. Increased sensation leads to small leakage of
53

2. BLADDER COMPLIANCE
54

BLADDER COMPLIANCE
 Compliance (ml/cm H O) = Change in volume (Δ V) / change in detrusor pressure (ΔPdet)
 Normal compliance is >30–40 ml/cm H2O.
 Abnormal compliance is <30–40 ml/cm H2O.
55

BLADDER COMPLIANCE
A) Normal compliance with each 30–40
ml increase in bladder volume causing
a less than 1 cm H2O increase in
pressure.
B) Seemingly poor compliance.
C) Artefactual poor compliance due to
high fill rate
D) True poor compliance: stopping filling
does not cause a drop in pressure and
filling further at any fill rate continues
to show poor compliance.
56

3. BLADDER CAPACITY
57

BLADDER CAPACITY
Cystometric capacity
 Bladder volume at the end of the storage phase
when ‘permission to void’ is given and the
investigation moves into the voiding phase.
 Usually the maximum cystometric capacity
 If it is not the MCC – define the reason why
fIlling was stopped
 pain, large infused volume or high detrusor
end filling pressure.
Maximum cystometric capacity (MCC)
 Normal sensations - volume at which the
patient feels he/she can no longer delay
micturition due to a strong desire to void.
 Where there is altered or absent sensation the
MCC cannot be measured and the cystometric
capacity should instead be recorded.
 Normal – 350 – 600ml
NORMAL - bladder should fill to a capacity of approximately 500 ml before there is a strong desire to void.
NO BENEFIT IN OVERFILLINGABOVE 650 -700 ML
58

4. DETRUSOR FUNCTION
59

DETRUSOR FUNCTION
 Normal detrusor function – During the storage phase, the bladder should be
relaxed and compliant to bladder filling with little or no change in detrusor pressure.
 Involuntary detrusor activity - Any detrusor activity prior to the voiding phase
60

DETRUSOR OVERACTIVITY
 Involuntary detrusor contractions (IDCs) during the storage phase
 Previous terminology - detrusor instability or detrusor hyper-reflexia
 Types:
 Phasic – having a characteristic waveform of repeated waves of DO.
 Terminal – an IDC occurring at cystometric capacity, which cannot be suppressed, and
results in incontinence/voiding.
 Idiopathic – when there is no defined cause for the overactivity – OVERACTIVE
BLADDER SYNDROME
 Neurogenic – when there is an underlying neurological condition causing the lower
urinary tract dysfunction.
61

DETRUSOR OVERACTIVITY – THINGSTO
LOOK IN UDE
 Volume at which the contraction occurred
 Rise in amplitude above the baseline
 Duration of the contraction
 If urgency was experienced in association with the
IDC
 Associated incontinence
62

HIGH PRESSURE DETRUSOR OVERACTIVITY
• Neurogenic detrusor
activity
63

PHASIC DETRUSOR OVERACTIVITY
Contraction activity with
increasingly frequent and
higher amplitude contractions
occur as the bladder
continues to be filled
64

TERMINAL
DETRUSOR
OA
Strong detrusor contraction occurring at urgency and
leading to complete bladder emptying.
65

COUGH INDUCED DETRUSOR OVERACTIVITY
• Det. OA associated
with increased intra
abdominal pressure
• Associated with
increased detrusor
pressure
• Should be differentiated
from stress urinary
incontinence when
associated with urine
leak
66

5. URETHRAL FUNCTION IN
STORAGE PHASE
67

URETHRAL FUNCTION DURING STORAGE
PHASE
 Normal – maintains continence in the presence of increased intraabdominal
pressure.
 Incompetent – allows leakage in the absence of a detrusor contraction.
 Urodynamic stress incontinence (USI) – involuntary leakage of urine during
increased intra-abdominal pressure, in the absence of a detrusor contraction
 Urethral relaxation incontinence – leakage due to urethral relaxation in the
absence of raised intra-abdominal pressure or detrusor overactivity.
68

LEAK POINT PRESSURES
 Abdominal leak point pressure (ALPP)
 Detrusor leak point pressure (DLPP)
69

ABDOMINAL LEAK POINT PRESSURE
 Intra-vesical pressure at which urine
leakage occurs due to increased
abdominal pressure in the absence of a
detrusor contraction.
 Measure of the ability of the bladder neck
and the urethral sphincter mechanism to
resist increases in intra-abdominal
pressure.
 Other terms -Valsalva leak point pressure
(VLPP), Cough leak point pressure
(CLPP)
ALPP (cm H2O) INFERENCE IN
INCONTINENCE
<60 Intrinsic sphincter
deficiency
60- 100 Equivocal
>100 Urethral
hypermobility
70

ALPP
71

URODYNAMIC STRESS INCONTINENCE
Leakage occurs during cough
without any concomitant detrusor
contraction
72

DETRUSOR LEAK POINT PRESSURE
 Lowest detrusor pressure at which urine leakage occurs in the absence of either a
detrusor contraction or increased abdominal pressure.
 Predicts upper tract dysfunction in patients with reduced bladder compliance and
poor voiding.
 Measures the capacity of the bladder neck and urethral sphincter mechanism to
resist increased pressure
Detrusor leak point pressure (DLPP) >40 cm H2O: suggests upper tract
deterioration likely
73

DETRUSOR LEAK POINT PRESSURE
74

VOIDING PHASE
Isovolumetric
contraction -
detrusor
initially
contracts
without a
change in
bladder volume
Bladder
continues to
contract -
Bladder outlet
‘opens’ and
urine begins to
be expelled
resulting in a
decrease in the
bladder volume
At the
completion of
voiding the
detrusor
relaxes and the
urethra/bladder
outlet ‘closes’
75

VOIDING PHASE MEASURES
FLOW PARAMETERS
 Flow rate (Q)
 Maximum flow rate (Qmax)
 Voided volume
 Voiding time
 Flow time
 Average flow rate
 Time to maximum flow.
PRESSURE PARAMETERS
 Pre-micturition pressure
 Opening pressure
 Opening time
 Maximum pressure
 Pressure at maximum flow
 Closing pressure
 Minimum voiding pressure
76

PRESSURE PARAMETERS INVOIDING
 Pre-micturition pressure – the
pressure recorded immediately before
the initial isovolumetric contraction.
 Opening pressure – the pressure
recorded at the onset of urine flow.
77

 Opening time – the time from initial
rise in detrusor pressure to onset of
flow; this refers to the initial
isovolumetric contraction period.
 Maximum pressure – the maximum
value of the measured pressure, i.e.
the peak amplitude of the voiding
pressure curve
78

 Pressure at maximum flow
(Pdet@Qmax) – the pressure recorded at
maximum measured flow rate.
 Closing pressure – the pressure measured
at the end of measured flow.
 Minimum voiding pressure – the minimum
pressure during measurable flow
79

DETRUSOR FUNCTION INVOIDING
NORMAL
DETRUSOR UNDERACTIVITY
ACONTRACTILE DETRUSOR
AFTER CONTRACTION
80

NORMAL DETRUSOR
 Voluntary continuous detrusor contraction which leads to complete emptying of the
bladder within an acceptable time span
81

DETRUSOR
UNDERACTIVITY
 Contraction of reduced
strength and/or duration,
resulting in prolonged
bladder emptying and/or
a failure to achieve
complete bladder
emptying within a normal
time span.
82

BLADDER CONTRACTILITY INDEX
 BCI = Pdet Qmax + 5 Qmax
 Measure of detrusor function
BCI (cmH2O) INFERENCE
>150 STRONG
CONTRACTILITY
100-150 NORMAL
<100 WEAK
CONTRACTILITY
83

ACONTRACTILE BLADDER
 Does not demonstrate any contractile activity during urodynamic assessment.
 CONSIDER!!! - ‘bashful’ bladder - cannot generate a detrusor contraction in the
laboratory setting
84

AFTER CONTRACTION
 A detrusor contraction which occurs
immediately after micturition has
ended
 Significance - unknown
 May be associated with detrusor
overactivity
85

URETHRAL FUNCTION INVOIDING
 Normal
 Bladder outlet obstruction
 Dysfunctional voiding
 Detrusor sphincter dyssynergia
 Non-relaxing urethral sphincter obstruction
86

NORMAL ELECTROMYOGRAM
EMG activity
increases during
bladder filling
and should be
almost silent
during voiding
(sphincter
relaxation) 87

BLADDER OUTLET OBSTRUCTION
URODYNAMIC
OBSTRUCTION:
• Detrusor pressure >60 cm H2O
• Qmax <10 mL/s
88

BOO WITH DO
Pressure/flow trace in patient with
both detrusor overactivity during
filling and BOO during voiding.
This is a common pattern as many
patients have both conditions
coexisting
89

BOO - INDEX
 Abrams–Griffiths (AG) number)
 BOOI = Pdet@Qmax − (2 × Qmax)
BOOI INFERENCE
<20 UNOBSTRUCTED
20-40 EQUIVOCAL
>40 OBSTRUCTED
90

ICS PRESSURE FLOW NOMOGRAM
Used to calculate the bladder outlet
obstruction index (BOOI)
by plotting Qmax against Pdet@Qmax.
Categorize patients as
being obstructed, unobstructed or
equivocal.
Based on a number of older nomograms
(Abrams–Griffiths,Schafer LinPURR
and URA nomograms)
Only the ICS nomogram is required in
routine clinical practice 91

ICS NOMOGRAMS
COMBINING BOOI
& BCI
92

DYSFUNCTIONALVOIDING
 Intermittent and/or
fluctuating flow rate due
to involuntary
intermittent
contractions of the peri-
urethral striated muscle
during voiding, in
neurologically normal
patients.
93

DETRUSOR SPHINCTER
DYSSYNERGIA
 Detrusor contraction concurrent with an
involuntary contraction of the urethral
and/or peri urethral striated muscle.
 Intermittent opening and closure of the
urethral sphincter causing a characteristic
flow pattern and pressure changes
94

95

TYPES OF DSD
Characterized by a
simultaneous increase of
detrusor pressure and
external sphincter EMG
activity that reaches its
maximum at the peak of
detrusor contraction.At this
point sudden complete
external relaxation occurs
allowing urination.
01
Characterized by clonic
contractions of the
external urethral
sphincter scattered
throughout detrusor
contraction. Patients
usually void with an
interrupted stream.
02
Characterized by an
external sphincter
contraction persisting
during the entire detrusor
contraction.These
patients void with an
obstructive stream or
cannot void at all
03
96

97

NON-RELAXING URETHRAL SPHINCTER
 Non-relaxing, obstructing urethra may result in reduced urine flow and tends to
occur in patients with a sacral or infra-sacral neurological lesion
 Meningomyelocoele or radical pelvic surgery.
98

URETHRAL PRESSURE PROFILOMETRY
Measured along the length of the
entire urethra by withdrawing the
measuring catheter mechanically at a
constant speed.
The resulting profile indicates the
pressures within the urethra from the
bladder neck to the meatus
Urethral closure pressure profile:
derived by the subtraction of intra-
vesical pressure from urethral
pressure.
99

URETHRAL PRESSURE PROFILOMETRY
 Maximum urethral pressure: The
maximum pressure of the measured
profile.
 Maximum urethral closure pressure
(MUCP): The maximum difference
between the urethral pressure and the
intra-vesical pressure.
 Functional profile length: The length
of the urethra along which the urethral
pressure exceeds intra-vesical pressure
Maximum urethral closure pressure <20 cm H2O: suggests intrinsic sphincter deficiency
100

BEFORE CONCLUDING…
Read all the pressure flow measurements in a wholistic manner
No individual measures should be interpreted separately
Interpret UDE always with clinical context
Look for artefacts and deduce them
Repeat UDE whenever necessary
101

Not as difficult as you
think…
Recommend UDE
whenever necessary…
102

THANK
YOU
103

URODYNAMICS

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URODYNAMICS