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

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

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

4. Bladder Diary

5. 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

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

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

8. 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

9. 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

10. Uroflowmetry – Normal flow

11. 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)

12. Uroflowmetry – Parameters

13. 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

14. Uroflowmetry – Intermittent flow

15. Uroflowmetry – Straining flow

16. Uroflowmetry – Low contractility

17. Uroflowmetry – Obstructive flow

18. 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

19. 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

20. Cystometry - technique

21. 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

22. Normal Cystometrogram
Resting pressure < 10 cm water
FSF at ml, FS at ml
Cystometric capacity at ml
Voiding pressure < 50 cm water in men and <35 cm water in women
A coordinated sphincter EMG activity

23. Cystometry- Neurogenic detrusor overactivity and DESD

24. Cystometry- Idiopathic detrusor overactivity

25. Cystometry- after contraction

26. 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

27. 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

28. Poor Bladder Compliance and Stress Urinary Incontinence

29. 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

30. 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

31. Pressure flow study - Technique

32. Multi-channel Pressure Flow Study

33. Relationship of Pressure & Flow

34. Pressure flow study – DHIC

35. Pressure flow study– Cystocele and BOO in woman

36. Low contractility & low flow

37. Detrusor overactivity & voluntary PFM contraction

38. Detrusor overactivity in Storage phase

39. Detrusor overactivity in a contracted bladder

40. Provoked DI in storage phase

41. 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

42. Urethral Pressure Profilometry

43. Stress UPP in Continent woman

44. Stress UPP in Incontinent woman

45. Nitric oxide UPP in Neuropathic bladder

46. Voluntary Pelvic floor contraction

47. 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

48. Abdominal Leak point pressure in Type I SUI

49. Abdominal leak point pressure in Type II SUI

50. Cough vs Valsalva LPP in Type II/III SUI

51. Cough vs Valsalva LPP in Type II/III SUI

52. Cough vs Valsalva LPP in Pure Type III SUI

53. LPP – Intravesical vs intra-abdominal recording

54. Valsalva LPP in Cystocele & SUI

55. 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

56. 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

57. Videourodynamic study in DI

58. Videourodynamic study in Female urethral stricture

59. Videourodynamic study in Female urethral stricture

60. Mixed DI and SUI

61. Poor relaxation of urethral sphincter

62. Low pressure and BOO

63. Dysfunctional voiding in woman with urge incontinence

64. Videourodynamic study in SUI

65. Videourodynamic study in SUI after Pubovaginal sling

66. Videourodynamics in Post-incontinence surgery BOO