Urodynamic Study in Lower Urinary Tract Dysfunction Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

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

Urinary Incontinence Stress incontinence Urge incontinence Total incontinence Overflow incontinence Giggle incontinence Nocturnal enuresis

Bladder Diary

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

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

Urodynamic study- Lower urinary tract Uroflowmetry Cystometrography External sphincter electromyography Pressure flow study Videourodynamic study Urethral pressure profilometry

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

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

Uroflowmetry – Normal flow

Normal Uroflowmetry Qmax > 15 ml/s in men Qmax > 20 ml/s in women Tqmax is < 1/3 of flow time Voided volume 200 –500 ml A normal flow pattern Minimal residual urine (< 50ml)

Uroflowmetry – Parameters

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

Uroflowmetry – Intermittent flow

Uroflowmetry – Straining flow

Uroflowmetry – Low contractility

Uroflowmetry – Obstructive flow

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

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

Cystometry - technique

Cystometrography Bladder sensation: FSF, FS, US,capacity Bladder compliance Detrusor pressure at end-filling stage Voiding pressure: Men < 50 cmH2O, Women <35cmH2O Coordination of external sphincter EMG

Normal Cystometrogram Resting pressure < 10 cm water FSF at 100-200ml, FS at 300-400 ml Cystometric capacity at 400-500 ml Voiding pressure < 50 cm water in men and <35 cm water in women A coordinated sphincter EMG activity

Cystometry- Neurogenic detrusor overactivity and DESD

Cystometry- Idiopathic detrusor overactivity

Cystometry- after contraction

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

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 >40 cm water might endanger upper tract

Poor Bladder Compliance and Stress Urinary Incontinence

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

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

Pressure flow study - Technique

Multi-channel Pressure Flow Study

Relationship of Pressure & Flow

Pressure flow study – DHIC

Pressure flow study– Cystocele and BOO in woman

Low contractility & low flow

Detrusor overactivity & voluntary PFM contraction

Detrusor overactivity in Storage phase

Detrusor overactivity in a contracted bladder

Provoked DI in storage phase

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

Urethral Pressure Profilometry

Stress UPP in Continent woman

Stress UPP in Incontinent woman

Nitric oxide UPP in Neuropathic bladder

Voluntary Pelvic floor contraction

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

Abdominal Leak point pressure in Type I SUI

Abdominal leak point pressure in Type II SUI

Cough vs Valsalva LPP in Type II/III SUI

Cough vs Valsalva LPP in Type II/III SUI

Cough vs Valsalva LPP in Pure Type III SUI

LPP – Intravesical vs intra-abdominal recording

Valsalva LPP in Cystocele & SUI

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

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

Videourodynamic study in DI

Videourodynamic study in Female urethral stricture

Videourodynamic study in Female urethral stricture

Mixed DI and SUI

Poor relaxation of urethral sphincter

Low pressure and BOO

Dysfunctional voiding in woman with urge incontinence

Videourodynamic study in SUI

Videourodynamic study in SUI after Pubovaginal sling

Videourodynamics in Post-incontinence surgery BOO