1. Dr Kiran Ashok Urogynecologist
Urodynamic studies
Dr Kiran Ashok
Urogynecologist

2. Irritation Anxiety Parkinsons Infection Urgency
Bladder responds similarly to variety of stimulants
Irritation
Anxiety
Parkinsons
Infection
Symptoms always do not reflect the actual state of bladder
Urgency

3. Urodynamics
Observation of the changing function of the lower urinary tract over time

4. Urodynamic testing

5. Uroflowmetry Filling cystometry Voiding cystometry or PFS
Measure the rate of urine flow
Uroflowmetry
Fill the bladder & measure
Bladder sensation
Bladder pressure
Bladder compliance
Filling cystometry
During voiding measure
urine flow & bladder pressure simultaneously
Voiding cystometry
or PFS

6. Principle of cystometry

7. Detrusor pressure = Vesical pressure- Abdominal pressure
catheter in the bladder measures vesical pressure
catheter in the vagina/rectum measures abdominal pressure
Detrusor pressure = Vesical pressure- Abdominal pressure

8. Technique of Cystometry

9. Quality check

11. Performing Urodynamic study
Clear indication
Specific question
-Is there detrusor overactivity?
-is there an increased bladder sensation?
-is the bladder compliance low?
-is SUI caused by intrinsic sphincter deficiency?

12. Urodynamic data should always be interpreted in association with clinical findings

13. Filling cystometry
Filling cystometry is the method by which the pressure/ volume relationship of the bladder is measured during bladder filling.
Double lumen catheter in the bladder – one for filling and the other for pressure measurement
Single lumen catheter in the vagina or rectum to measure abdominal pressure
Leak point pressure measurements are done in filling cystometry

14. Normal filling cystometry

15. Increased bladder sensation
Increased bladder sensation is defined as an early first sensation of bladder filling or an early strong desire to void that occurs at what is felt to be a low bladder volume and ultimately persists

16. Filling cystometry – bladder sensations

17. Detrusor pressure
Detrusor pressure during filling should be very low with no involuntary contractions.
Detrusor overactivity (DO) is defined as involuntary detrusor contractions during filling that may be spontaneous or provoked

18. Detrusor Overactivity

19. Clinically significant detrusor contractions are those which are associated with patient symptoms

20. Cough Induced DO

21. Cough induced DO

22. Provocative maneuvers to elicit DO

23. Urodynamic stress incontinence
 This diagnosis by symptom, sign and urodynamic investigations involves the finding of involuntary leakage during filling cystometry, associated with increased intra-abdominal pressure, in the absence of a detrusor contraction
Standerdization of terminology. Int Urogyncol J 2010;21(1):5-26

24. Urodynamic stress incontinence
leak
Cough

25. Urodynamic Stress Incontinence
Leak

26. Leak point pressure
The lower the LPP, the weaker is the urethral sphincter

27. Valsalva Leak point pressure (VLPP)
Defined as the intravesical pressure in which urine leakage occurs because of an increased abdominal pressure in the absence of a detrusor contraction Leak point pressure is a measure of the intrinsic sphincter strength of the urethra or its ability to resist leakage with increases in abdominal pressure.

28. Mixed urinary Incontinence

29. Bladder Compliance
The bladder needs to accommodate the increase in volume without an appreciable rise in bladder pressure.
This receptive relaxation property is called bladder compliance
Compliance (ml/cm H2O) = change in volume (ΔV) / change in pressure (ΔPdet)

30. Bladder compliance

31. Abnormal compliance is related to filling while DO is not
Steady raise in detrusor pressure which plateues when filling is stopped and increases when filling is resumed – poor bladder compliance
Abnormal compliance is related to filling while DO is not

32. Abnormal bladder compliance
Neurogenic bladdder
Prior bladder radiation exposure
Multiple bladder surgeries
Bladder tuberculosis
Recurrent UTI
Long standing BOO

33. Postvoid residual (PVR) urine volume
This is an objective assessment of how well a woman empties her bladder. It can be performed by ultrasound or bladder scan or direct catheterization. An elevation of the PVR indicates a problem with emptying

34. Voiding symptoms Uroflowmetry PVR Voiding cystometry Slow stream
Straining to void
Feeling of incomplete bladder emptying
Urinary retention
Uroflowmetry
PVR
Voiding cystometry

35. Uroflowmetry

36. Uroflowmetry
Uroflowmetry is a measurement of the rate of urine flow over time
It is also an assessment of bladder emptying
When the flow rate is reduced or the pattern is altered, this may indicate bladder underactivity or bladder outlet obstruction

37. Uroflowmetry
Uroflowmetry is noninvasive, inexpensive and is best used as a screening test for patients who may have voiding dysfunction.

38. A normal uroflow is a bell shaped curve

39. Various Uroflow patterns
Detrusor overactivity
Straining producing irregular tracing
Bladder outlet obstruction
Intermittant flow

40. Interrupted Flow – inappropriate pelvic floor muscle contractions

41. Measure bladder pressure simultaneously with the flow
Low rate of urine flow
Underactive detrusor
Obstruction
How to diagnose?
Measure bladder pressure simultaneously with the flow
PFS
High bladder pressure
Low bladder pressure
Underactive detrusor
Obstruction

42. Female bladder outlet obstruction
Previous
Anti-incontinence surgery
Anatomic distortion
due to cystocele
Neurogenic
Vaginal mass/cyst/rectocele
Compressing urethra
Inability to relax pelvic floor – traumatic delivery/ pelvic surgery, Anxiety

43. Voiding cystometry (pressure flow study)

44. Low flow + No/ minimal raise in detrusor pressure
Voiding cystometry
Low flow + High detrusor prssure
Obstruction
Underactive
detrusor
Low flow + No/ minimal raise in detrusor pressure

45. PFS Pressure flow studies are invasive
Patient is asked to void with the catheters
May not accurately represent normal voiding

46. Normal pressure flow

47. Obstructed flow

48. Obstruction after TVT

49. Electromyogram (EMG)
The study of electronic potentials produced by muscle membranes.
Basically to know the action of a muscle
EMG is performed with patch electrodes placed on either side of perineum
The test is mostly used to assure appropriate coordination between the pelvic floor muscles and lower urinary tract

50. EMG during normal filling and voiding
Muscle action during filling
Muscle relaxed during voiding

51. Comparing normal cystometry with neurogenic bladder

52. Detrusor –Sphincter dyssynergia

53. Urodynamic studies - indications

54. In women with SUI without any other urinary symptoms, UDS are not indicated
NICE guidelines 2006

55. Indications for UDS in SUI
Mixed incontinence (coexistent DO)
Women who have previously undergone surgery for SUI and developed recurrent incontinence
Previous anterior compartment prolapse surgery
Women with symptoms suggestive of significant voiding dysfunction.

56. Pelvic organ prolapse – role of UDS
In patients who have lower urinary tract symptoms in conjunction with their prolapse
Have evidence of voiding difficulty
Outlet obstruction as noted by high PVR

57. UDS in Overactive bladder
conservative or drug therapy fails
Indications
considering an invasive intervention
What to expect
Increased bladder sensations
Detrusor overactivity

58. UDS in Mixed Urinary Incontinence
Helps to determine the predominant condition – SUI or UUI
Detect DO or Increased bladder sensations

59. Complications of UDS
Pain
Infection
Hematuria
Retention

60. Thank you

61. To confirm the effects/Adverse effects of intervention or understand the mode of action of a particular type of treatment
Voiding dysfunction after TVT

62. Multichannel urodynamic tests are useful for the assessment of bladder neuropathy and voiding dysfunction.

63. The use of a VLPP and UPP measurement to assess urethra dysfunction has produced disappointing results.
Evolving consensus appears to be that urodynamics is not necessary in all cases of pure SUI and
a limited predictive role of lower urinary tract symptoms after anti-incontinence procedures.

64. Urinary bladder responds similarly to a variety of pathologies
Symptoms do not always reflect the actual state of the bladder
Eg: woman may feel that her bladder is full, when in fact it may actually be nearly empty

66. Normal micturition

67. Normal Urodynamic study

69. Detrusor overctivity with leak

70. Fluctuating detrusor pressures

71. Detrusor overactivity

72. Detrusor overactivity

73. Clinician should be actively interacting with the patient
Clinician should be actively interacting with the patient. There should be continuous observation and collection of data
Pre-procedure Antibiotic prohylaxis indicated in high risk patients

74. An abdominal leak point pressure is a measure of the intrinsic sphincter strength of the urethra or its ability to resist leakage with increases in abdominal pressure.
It is specifically defined as the intravesical pressure in which urine leakage occurs because of an increased abdominal pressure in the absence of a detrusor contraction.
Thus it is an objective assessment of the amount of abdominal pressure required to overcome outlet resistance and create leakage.

75. Uroflowmetry

76. Pressure flow study
Measures pressures in the bladder when a woman is voiding. Detrusor pressure is measured along with simultaneous measurement of urine flow
Essential for assesment of voiding dysfunction

77. Voiding cystometry (PFS)
Normal voiding is usually achieved by a voluntarily initiated continuous detrusor contraction that is sustained and can be suppressed.

78. Bladder outlet obstruction for whatever reason is characterized by increased detrusor pressure and reduced urine flow rate

79. Filling and voiding cystometry

80. UPP

81. Detrusor sphincter dyssynergia

82. Detrusor acontractility
Neurogenic bladder
Abnormal compliance DO
Filling cystometry
BOO Vs
Detrusor acontractility
Voiding cystometry
EMG
DSD