1. Evaluation of Lower Urinary Tract Symptoms (LUTS)
Jerry G. Blaivas, MD
Clinical Professor of Urology
Weil-Cornell College of Medicine
Adjunct Professor of Urology
SUNY Downstate Medical Center

2. Lower Urinary Tract Symptoms (LUTS)
Storage symptoms (irritative symptoms)
Voiding symptoms (obstructive symptoms)

3. Storage Voiding Frequency Weak stream Urgency Hesitancy Incontinence
Nocturia
Pain
Weak stream
Hesitancy
Incomplete emptying
Urinary retention
Post void dribbling
Storage & voiding sx may be due to the bladder, the outlet or both bladder and outlet

4. Storage Symptoms Because of the Bladder
Detrusor overactivity
Idiopathic
Non-neurogenic (pathologic)
Neurogenic
Low bladder compliance
Sensory urge
Fistula

5. Storage Symptoms Because of the Sphincter
Functional classification
Urethral hypermobility
Intrinsic sphincter deficiency
Anatomic classification
Type SUI

6. Voiding Symptoms Because of the Bladder
Impaired detrusor contractility neurogenic myogenic acquired behavior
Detrusor overactivity

7. Emptying Problems Because of the Outlet
Anatomic:
prolapse
prior surgery
urethral diverticulum
urethral stricture
primary bladder neck
Functional
dyssynergia
acquired behavior
primary bladder neck

8. Diagnostic Evaluation: Goals
Define underlying pathophysiology
Assess risk factors & co-morbidities
Identify remediable conditions
Formulate treatment plan

9. Underlying Pathophysiology
Detrusor overactivity
Sensory urgency
Urethral obstruction
Sphincter dysfunction
Impaired detrusor contractility
Fistula
Polyuria

10. Identify Risk Factors Detrusor sphincter dyssynergia
Low bladder compliance
Significant urethral obstruction
Grade 3 – 4 POP

11. Evaluation History & physical exam Questionnaire Urinalysis & culture
Bladder diary
Post void residual urine (PVR)

12. Evaluation (cont’d) Uroflow (Q) Pad test Cystoscopy Urodynamics
Urinary tract imaging

13. Imaging Pelvis Urinary Tract Ultrasound: Renal Ultrasound Vaginal
Perineal
Abdominal
CT scan
MRI
Urinary Tract
Renal Ultrasound
CT scan
MRI
Cystogram & VCUG

14. CYSTOGRAM & VCUG
Cystogram - Radiographjc imaging of of the bladder during filling
VCUG (Voiding cysto-urethrogram) - Radiographic imaging of the bladder and urethra during voiding

15. CYSTOGRAM & VCUG Integrity of the sphincter
Type & degree of urethral mobility
Site of obstruction (narrowest part of the urethra during voiding)
Vesico-ureteral reflux
Bladder & urethral diverticula

16. Indications for Imaging*
hematuria
neurogenic bladder
significant post-void residual
flank, abdominal or pelvic pain
untreated grade 3 – 4 POP
extra-urethral incontinence
low bladder compliance
*4th ICI, 2008 (and me)

17. History Questionnaire Patient interview Each symptom assessed by:
frequency of occurrence
severity
how bothersome

18. History
Prior Rx
Medications
Review of systems
Previous surgery

19. Physical Examination General Neurologic Uro - gynecologic
Neuro - urologic perianal sensation anal sphincter tone anal sphincter control b–c reflex

20. 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

21. Variable Mean /Median Day-time volume (ml) 1261 (721)
Night-time volume (ml)
468 (414)
Frequency Day
6.7 (6.5)
Frequency Night
0.4 (0.3)
Bladder Capacity day
229 (220)
Bladder capacity night
332 (294)
24hr Volume
1729 (1619)
24hr Frequency
7.1 (6.8)
Minimum void volume
81 (47)
Maximum void volume
514 (190)
Table 1. Normal urinary outputs. *Extrapolated from Amundsen, 2007; Parsons, 2006)

22. OAB Bladder Diary Instructions
Why did you urinate?
(0) Out of convenience (no urge or desire)
(1) Mild urge (but can delay urination for an hr)
(2) Moderate urge (can delay > 10 but <60 min)
(3) Severe urge (can delay for < 10 min)
(4) Desperate urge (must go immediately)
Incontinence grade:
Grade 1 - some drops Grade 2 - moderate loss (wet underpants) Grade 3 - extensive loss (wet outer clothes)

23. OAB Diary Time UPS Volume (ml) Incontinence Grade 6 AM 4 120 1 7:30 390
8:00
9:10
12:30 2
5:50 60
10:00 30
12:00
100
3:00
8:40
6:00
Here is a typical OAB patient. Bed time is shaded in blue; OAB voids are shaded yellow. She voids 11 times in 24 hours and has 5 urgency voids (UPS 3 – 4). Her 24 hour volume is only 1110 ml, so she has already consciously or unconsciously restricted her fluid intake. Her bladder capacity is only 120 ml. Npi = .34, so nocturnal polyuria does not contribute to her symptoms.

24. 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)

25. 24 Hour Pad Test Patient changes pads PRN Put each pad in plastic bag
Bring pads to next office visit
Weigh pads (1 gm = 1 ml urine loss)
normal < 8 gms/24 hours

26. Post Void Residual Urine
Assessment of emptying efficiency
Measured by ultrasound or catheter (when there is a need for catheterization)
Results may prompt further study

27. Post Void Residual Urine
An elevated PVR only 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

28. Post Void Residual Urine
A low PVR does not exclude urethral obstruction
PVR has very larger intra-individual variability
PVR should be repeated many times before clinical judgments are made

29. Uroflow (Q)
Functional evaluation of interaction between the bladder & urethra
Low flow: bladder outlet obstruction impaired detrusor contractility
Evaluate Qmax, Qave & shape of curve

30. Uroflow ml/S 20 10 Seconds Normal Obstructed Impaired contractility
Acquired voiding dysfunction 20 10
Seconds

31. Indications for Q & PVR*
Voiding symptoms
Elevated PVR
Results may prompt further investigation
I get Q & PVR in all patients
*4th ICI, 2008

32. Indications for Cystoscopy*
hematuria
sterile pyuria
pelvic/bladder/urethral pain
vesicovaginal fistula
extra-urethral incontinence
4th ICI, 2008

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

34. Risk Factors Detrusor sphincter dyssynergia Low bladder compliance
Significant urethral obstruction
Grade 3 – 4 POP

35. Basic Urodynamics Cystometry Leak point pressure Uroflow PVR
Cystogram & VCUG

36. Advanced Urodynamics Synchronous Pdet/Q Sphincter EMG
Dynamic & micturitional UPP
Videourodynamics
Computer indices of detrusor contractility & urethral obstruction

37. 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

38. Prior to Urodynamics What are the symptoms?
Functional bladder capacity
Uroflow
Postvoid residual urine
Neurologic lesion?
Formulate questions to be
answered by the study

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

40. Indications for Urodynamics
Empiric treatment associated with risk
Irreversible or potentially morbid treatment is planned
Risk of renal or bladder damage from pre-existing conditions (radiation, NGB)
Harmful sequelae can occur in the absence of symptoms

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

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

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

44. Idealized CMG
Storage
Voiding
pdet
Volume

45. (Figure 3 A) With just the Pves tracing you have very limited or no information about what is happening. Black arrow - is this an artifact, straining, cough, etc..? Red arrow – this looks like straining, but it could be a short lived detrusor contraction. Blue arrow – Is the patient straining or is this a detrusor contraction?

46. (Figure 3 B) More information is attained by displaying pabd
(Figure 3 B) More information is attained by displaying pabd. The black arrows confirm that there is an equal rise in both vesical and abdominal pressure. This confirms that the rise in pves was due to a rise in pabd. The narrow spike in pressure suggests that these are coughs, but the only way of knowing for sure is by watching and talking to the patient. We now know these are times the patient coughed. At the red arrow there is a rise in pves with no corresponding rise in abdominal pressure. The only explanation for this is that the patient is having a detrusor contraction. At the blue arrow, there is a nearly equal rise in pves and pabd. There are two possibilities to account for this –The patient may be straining during a detrusor contraction or there is a calibration error. The fact that the pressures at the black arrows were transmitted equally prove that this is a detrusor contraction accompanied by straining.

47. (Figure 3 C) Visualizing all three pressures simultaneously, permits a definitive diagnosis. The black arrows point to coughs (pves & pabd rise equally) The red arrow shows a detrusor contraction. The blue arrow also points to a detrusor contraction, but when you also look at pabd it is apparent that the patient is straining. The result is that the detrusor contraction appears on the pves tracing to be much higher than it really is.

48. Observe height of water column Account for every rise in pressure:
Gravity filling
Talk to patient
Observe height of water column
Account for every rise in pressure:
detrusor contraction
increase in abdominal pressure
low compliance
Observe for incontinence

49. Caveats CMG only assesses the bladder’s response to filling
Many CMG abnormalities are caused by voiding dysfunction
If CMG alone is done, underlying problem may be missed

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

51. Urethral Obstruction Normal or high voiding pressure
Decreased uroflow Qmax < 12 mL.S
> 20 cm H20

52. Blaivas - Groutz Nomogram

53. Impaired Detrusor Contractility
Decreased voiding pressure
Decreased uroflow Qmax < 12 mL.S
< 20 cm H20

54. 2
Strss
Low flow
High pressure

55. Low flow
Low pressure JK

56. Videourodynamics
Combines urodynamics with fluoroscopic imaging of the LUT during
bladder filling
provocative maneuvers
voiding
Most accurate means of assessment
Each parameter serves as a check against the others

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

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

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

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

62. 50O

63. 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

64. Rwn
No leak
Cough

65. Rwn
leak
VLPP
Cough
VLLP = 45 cm H20
Qtip = 0 > 10O

67. VLPP VLLP = 92 cm H20 Qtip = 0 > 60O AG AG AG
Figure 9. Stress incontinence with urethral hypermobility and type 1 OAB. This corresponds to Type 2 SUI according to the Blaivas/Green/McGuire classification. AG is a 51 year old white woman with a chief complaint of gradually worsening stress incontinence of 10 years duration. About once or twice a month she soaks her clothes when she has been walking or does high impact aerobics. She wears one mini-pad all day which, at the end of the day is damp; "sometimes they're wetter than others”. She also gets urgency & urge incontinence when she puts the key in her door lock, but has learned to control this by voiding beforehand.
A.Urodynamic tracing. FSF = 10 ml; First urge = 251 ml; Severe urge = 492 ml. VLLP = 85 cm H2O. Bladder capacity = 585 cm H20. When asked to void, she strained a bit, but could not generate a detrusor contraction and was unable to void (light blue oval). VLPP = 50 cm H20 AG AG AG

68. Figure 9 B. X-ray exposed at VLPP shows rotational descent of the urethra and incontinence. Q-tip angle was 65O.
Comment: AG has classic type 2 stress incontinence and would likely do well after anti-incontinence surgery, but when advised of the remote possibility of urinary retention, elected behavioral therapy. AG

69. Urethral Hypermobility vs ISD Fleischmann et al J Urol 169:999, 2003
No correlation of ALPP with hypermobility:
ALPP < 60 24% hypermobile
ALPP % hypermobile
ALPP > % hypermobile
Fleischmann et al, J. Urol 169(3): , 2003

70. Urethral Hypermobility vs ISD Fleischmann et al J Urol 169:999, 2003
LPP & mobility do not correlate with incontinence episodes or pad weight
ISD and hypermobility do not define discrete classes of patient
Use LPP & mobility parameters to characterize not classify
Fleischmann et al, J. Urol 169(3): , 2003.

71. Evaluation of OAB
HX, PE (prolapse, urethral tic, NGB, UTI, bladder cancer) UA
Bladder diary (voiding frequency, urge voids, maximum voided volume)
Q & PVR (urethral obstruction, impaired contractility retention)

72. Urodynamic Evaluation of OAB
Etiology
detrusor overactivity
sensory urgency
Classification (based on control mechanisms)

73. Detrusor Overactivity (DO)
Idiopathic (detrusor instability)
Pathologic (detrusor instability)
Neurologic (NDO, detrusor hyperreflexia)

74. Idiopathic Detrusor Overactivity

75. Involuntary Contraction
incontinent
Involuntary Contraction
Can’t hold any longer
Trying to hold BA

76. Pathologic DO Urinary tract infection Genital prolapse
Sphincteric incontinence
Urethral obstruction
Bladder cancer
Bladder stones

77. Pathologic Detrusor Overactivity Grade 3 prolapse Grade 1 urethral obstruction

78. Involuntary detrusor contraction
Incontinent
Involuntary detrusor contraction
Figure 3. Grade 3 prolapse and grade 2 urethral obstruction in a 76-year-old woman. Her chief complaint is OAB and “a dropped bladder.” Cystoscopy showed that the bladder prolapsed posterior to the trigone. The ureteral orifices did not descend with the cystocele.
A. Urodynamic study:: FSF = 269 m; 1st urge = 302 ml; severe urge = 426 ml ml; contract her sphincter = yes; stop the flow = yes; abort detrusor contraction.= yes. Bladder capacity = 510 ml; . Qmax = 6 ml/S, Qmax = 28.4cm H2O, Pdetmax = 45 cm H2O; Voided volume = 160 ml, PVR = 344 ml . The EMG was not working. FK

79. Urethral meatus Urethral catheter cystocele
Figure 3 B. X-ray exposed just prior to the onset of micturition.
cystocele

80. Pathologic Detrusor Overactivity Bladder cancer

81. Bladder tumor (filling defects)
Involuntary detrusor contractions

83. Remediable Causes of DO
Urinary tract infection
Urethral obstruction
Stress incontinence
Urethral diverticulum

84. Remediable Causes of DO
Foreign body
Genital prolapse
Bladder stones
Bladder cancer

85. Sensory Urgency
An uncomfortable urge to void unassociated with detrusor overactivity
Synonymous with hypersensitive bladder and painful bladder syndromes

86. Sensory Urgency
Severe urge to void
Low bladder volume
Stable bladder

87. Sensory Urgency Etiology
Urinary tract infection
Bladder outlet obstruction
Idiopathic
Bladder stones
Acquired behavior
Bladder cancer

88. Evaluation of NGB
HX, PE (extent of neurologic deficit, urinary retention, febrile UTI)
Urinalysis
+/- Bladder diary & pad test
+/- Q & PVR
Videourodynamics
+/- upper tract imaging

89. Neurogenic DO Stroke Parkinson's disease Multiple sclerosis
Spina bifida
Transverse myelopathy
spinal cord injury
transverse myelitis
tumor

90. Detrusor Hyperreflexia
Synergy
Stroke
Parkinson’s
MS(supraspinal)
Spina bifida
Dyssynergy
SCI
MS (spinal)
Spina bifida

91. PR incontinent Can’t hold any longer No flow Involuntary Contraction
Trying to hold

92. Obstruction due to sphincter contractionPS
Involuntary detrusor contraction
Involuntary sphincter contraction

93. 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

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

95. Vesico-ureteral reflux
Steep rise in pressure DS

96. Vesico-ureteral reflux
Involuntary detrusor contraction
Stop filling DS

97. Detrusor Leak Point Pressure (DLPP)
Fill bladder until leakage occurs
DLPP = Pdet at leakage
For any bladder, the higher the DLLP, the higher the urethral resistance
Untreated, a high DLPP poses high risk for renal damage
DLPP is related to bladder compliance & urethral resistance

98. DLPP DS

99. 2

100. Evaluation of Voiding Symptoms
HX, PE (prolapse, urethral tic, NGB)
Urinalysis
Bladder diary
Q & PVR (urethral obstruction, impaired contractility, retention)

101. Patient: 51 y/o woman
History: “pot belly” > plastic surgeon for abdominoplasty > palpable bladder > PVR = 2100 ml
SSTRS

102. Exam: palpable bladder, normal neurologic
Uroflow: 4 ml/S , interrupted pattern, voided volume = 150 ml
PVR: 810 ml
Cystoscopy: 3+ trabeculation, two large bladder diverticula
SSTRS

103. 2
Strss

105. SSTRS
Treatment: Transurethral resection of vesical neck (2 gms)
Pathology: fibromuscular tissue lined with urothelium with squamous metaplasia
Uroflow: 31 ml/S , normal pattern, voided volume = 400 ml
PVR: 95 ml

106. 50
SSTRS
Flow
Ml/S

107. SS Post -op