Diagnostic Evaluation of Lower Urinary Tract Symptoms in Women Jeffrey P. Weiss, MD, FACS Professor and Chair Department of Urology SUNY Downstate College of Medicine VA NY Harbor Healthcare System Brooklyn, NY

Lower Urinary Tract Symptoms (LUTS) Storage symptoms (irritative symptoms) Emptying symptoms (obstructive symptoms)

Storage Symptoms Urinary Frequency Urgency Nocturia Incontinence Pain

Voiding Symptoms Hesitancy / Weak Stream / Straining Incomplete emptying Urinary Retention Pain

Dysuria Perineal “Aching” Inner Aspect Of Thighs Suprapubic Fullness

Conditions causing symptoms Urethral obstruction Impaired detrusor contractility Detrusor overactivity Low bladder compliance Sensory urgency Learned voiding dysfunction Polyuria

Differential Diagnosis OAB Pelvic prolapse Urethral stricture Neurogenic voiding dysfunction Urethral diverticulum Acquired voiding dysfunction Diabetes insipidus

Remediable Conditions Storage –Sphincteric incontinence –Fistula –Overactive bladder Voiding –Prolapse –acquired voiding dysfunction –urethral diverticulum –urethral stricture –primary bladder neck obstruction

Evaluation History & physical exam Questionnaire Urinalysis & culture Voiding diary

Physical Examination General Urologic Neurologic Neuro-urologic

Physical Examination General – Cognitive function –Signs of CHF –Peripheral edema Urologic –Exam with full bladder for SUI –Pelvic prolapse: location –Palpable urethral mass –Vaginal mucosal health

Physical Examination Neurologic –Cognitive function –Gait –Muscular strength –Deep tendon reflexes Neurourologic –Perianal sensation –Anal sphincter tone & control –Bulbocavernosus reflex

Bladder Diary Essential component of the w/u Time & amount of each urination Description of symptoms +/- oral intake The diary is a snapshot to be compared to day to day sx

Voiding Diary

Pad Test Useful for quantifying the amount of urine loss – two kinds: Stress pad test (20 min – 1 hour) (to provoke incontinence) 24 hour – 3 day – 7 day pad test ( to mimic typical day)

Evaluation Q & PVR Urodynamics Cystoscopy Upper tract imaging Renal ultrasound CTU

Uroflow Functional evaluation of interaction between the bladder & urethra Low flow: bladder outlet obstruction impaired detrusor contractility Normal flow: does not exclude obstruction

ml/S Uroflow Normal Seconds Obstructed Impaired contractility Acquired voiding dysfunction

Post Void Residual Urine Ultrasound Catheterization Contrast imaging study

Post Void Residual Urine An elevated PVR means that the bladder did not contract strongly enough for that urethra during that particular micturition It does not necessarily mean there is bladder outlet obstruction A low PVR does not exclude urethral obstruction Highly variable and should be repeated

Upper Tract Imaging (indications) Significant urethral obstruction Detrusor sphincter dyssynergia Low bladder compliance Adult onset enuresis Women with LUTS & low Q who don’t want RX

Indications for Cystoscopy* hematuria sterile pyuria pelvic/bladder/urethral pain vesicovaginal fistula extra-urethral incontinence I do cystoscopy preoperatively on all patients including prolapse To be sure there are 2 ureteral orifices No surprises 4 th ICI, 2008

Urodynamics: Purpose Reproduce symptoms Diagnose pathophysiology of underlying symptoms Identify risk factors Direct treatment Prognosticate

Urodynamics An interactive test between patient & physician The findings must be interpreted at the time of the study It is not possible to interpret the study by looking at the tracings afterwards unless there has been a detailed annotation

Prior to Urodynamics What are the symptoms? Was SUI or prolapse found on exam? Neurologic lesion? Bladder capacity (MVV) Q & PVR Formulate questions to be answered by the study

Indications for Urodynamics Low uroflow High PVR Uncertain diagnosis Finding that requires further evaluation Persistent symptoms despite apparently appropriate treatment

Storage Phase Urodynamics Cystometrogram (CMG) Leak Point Pressure Urethral Pressure Measurements EMG Cystogram

Emptying Phase Urodynamics Detrusor pressure – uroflow study Micturitional urethral pressure profile Sphincter electromyography (EMG) Post void residual Voiding cystourethrogram

Cystometry (CMG) Measurement of bladder pressure and volume during bladder filling: Bladder sensations Bladder pressure Involuntary bladder contractions Bladder compliance Bladder capacity Control over micturition

Cystometry Once aware, can she contract the sphincter ? Does sphincter contraction abort the stream? Does sphincter contraction abort the detrusor contraction?

Idealized CMG pdet Volume Storage Voiding

Videourodynamics Combines urodynamics with fluoroscopic imaging of the LUT during –bladder filling –provocative maneuvers –voiding Most accurate means of assessment

(Voiding) Detrusor Pressure Uroflow Study Urethral obstruction = high detrusor pressure & low uroflow Impaired detrusor contractility = low or poorly sustained detrusor pressure & low flow

2 Strss High pressure Low flow

JK Low pressure Low flow

Evaluation of Incontinence HX, PE (observation of SUI, prolapse) UA Q-tip test Bladder diary (incontinence episodes) Pad test Q & PVR (straining pattern)

Conditions Causing Incontinence Bladder problems – Detrusor overactivity – Low bladder compliance – Fistula Sphincter problems – Urethral hypermobility – Intrinsic sphincter deficiency

Q-tip test Place lubricated Q-tip into meatus Record resting angle Record maximum deflection during cough and strain Hypermobility > 30 O deflection A measure of urethral mobility

Q-tip Test > 30 O = hypermobility Cough or strain

Vesical Leak Point Pressure (VLPP) The bladder is filled with 150 ml The patient coughs or strains VLPP = Pves at leakage Low VLPP = intrinsic sphincter deficiency A means of quantitating intrinsic sphincter strength

Rwn No leak Cough

Rwn VLPP leak Cough VLPP = 45 cm H 2 0 Qtip = 0 > 10 O

Mixed Stress & Urge Incontinence Difficult diagnostic problem “If I wait too long, I leak…” Relative severity of each Differential diagnosis: Stress hyperreflexia SUI & DO SUI & sensory urgency

Voi Rbn Involuntary detrusor contraction Incontinent VLPP = 60

Formulating a Treatment Plan Diary Pad test Patient activity level & lifestyle VLPP Q-tip angle Bother index Patient preferences

Urodynamic Diagnoses Urethral obstruction Impaired detrusor contractility Detrusor overactivity Low bladder compliance Sensory urgency Learned voiding dysfunction

Female Urethral Obstruction High detrusor pressure: > 20 cm H 2 0 Low uroflow: Qmax < 15 ml/S Site of obstruction = narrowest point of urethra during voiding

Urethral Obstruction: 5 Main Causes in Women Pelvic prolapse Urethral diverticulum Urethral stricture Bladder neck obstruction Pelvic floor dysfunction DESD

Free Flow Qmax (ml/S)

Urodynamic Diagnoses Urethral obstruction Impaired detrusor contractility Detrusor overactivity Low bladder compliance Sensory urgency Learned voiding dysfunction

Idiopathic Neurogenic Overdistension Decompensation Pharmacologic Psychologic Etiology Of Impaired Detrusor Contractility

Urodynamic Diagnoses Urethral obstruction Impaired detrusor contractility Detrusor overactivity Low bladder compliance Sensory urgency Learned voiding dysfunction

Detrusor Overactivity Hyperreflexia = neurologic stroke Parkinson's disease multiple sclerosis transverse myelopathy Instability = non–neurologic urinary tract infection urethral obstruction bladder cancer bladder stones idiopathic

pdet Q EMG pabd pves Bladder volume

pdet Q EMG pabd pves Bladder volume

pdet Q EMG pabd pves involuntary detrusor contraction Involuntary sphincter contraction

pdet Q EMG pabd pves involuntary detrusor contraction Involuntary sphincter contraction

Urodynamic Diagnoses Urethral obstruction Impaired detrusor contractility Detrusor overactivity Low bladder compliance Sensory urgency Learned voiding dysfunction

BLADDER COMPLIANCE The ratio of a small change in bladder volume to a small change in detrusor pressure bladder vol. = bladder compliance pdet A measure of bladder wall "stiffness” High filling pressures are more clinically relevant

Causes of Low Bladder Compliance Myelodysplasia Thoracolumbar SCI Indwelling catheter Bladder surgery Urethral obstruction

pdet Q EMG pabd pves Bladder volume

DS Stop filling Involuntary detrusor contraction Vesico-ureteral reflux

Urodynamic Diagnoses Urethral obstruction Impaired detrusor contractility Detrusor overactivity Low bladder compliance Sensory urgency Learned voiding dysfunction

SENSORY URGENCY An uncomfortable urge to void unassociated with detrusor overactivity Synonymous with hypersensitive bladder and painful bladder syndromes

SENSORY URGENCY Severe urge to void Low bladder volume Stable bladder

Urodynamic Diagnoses Urethral obstruction Impaired detrusor contractility Detrusor overactivity Low bladder compliance Sensory urgency Learned voiding dysfunction

Learned Voiding Dysfunction Voluntary or involuntary, conscious or unconscious contractions of the striated urethral musculature Inability to relax the striated urethral muscles Inability to relax the smooth urethral muscles

ml/S Uroflow Seconds Acquired voiding dysfunction

Conclusions LUTS are fairly non-specific Very poor correlation between sx & underlying pathophysiology So, the more complete the workup, the greater the likelihood of attaining the correct diagnosis

Conclusions Essential ingredients of a good w/up: –Focused history & exam –Clear understanding of patient complaints –Bladder diary –Q & PVR –Videourodynamics is the gold standard –Cystoscopy & upper tract imaging when indicated