1. Selected Clinical Topics in Urology This presentation was created with funding from Pfizer Inc.

2. Urodynamics Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

3. Urodynamics  Introduction  Functional Classification of Voiding Dysfunction  Simple Tests  The Urodynamics Test  Videourodynamics  Urodynamic Risk Factors Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

4. Urodynamics  The lower urinary tract has two essential functions:  the storage of urine at low pressure  and the voluntary evacuation of urine  Low pressures are essential to protect kidneys and assure continence while voluntary evacuation allows for the elimination of urine in socially acceptable situations without fear of leakage or overdistension Introduction Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

5. Urodynamics  It is clear that a number of diseases affect the lower urinary tract and disrupt the storage and/or evacuation of urine  This can lead to bothersome symptoms (eg, urinary incontinence or pain from failure to empty) or in some cases potentially harmful sequela  In many cases, a precise assessment of storage and emptying is necessary to optimally treat patients Introduction Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

6. Urodynamics  Urodynamics (UDS) is the dynamic study of the transport, storage and evacuation of urine  It is comprised of a number of tests which individually or collectively can be used to gain information about urine storage and evacuation Introduction Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

7. Urodynamics  UDS is most useful when  history, physical exam and simple tests are not sufficient to make an accurate diagnosis and/or institute treatment  In some cases this may be to obtain an accurate diagnosis for what condition is causing symptoms  eg, lower urinary tract symptoms or incontinence Introduction UDS: Urodynamics Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

8. Urodynamics  In others it may be to determine the impact of a disease that can cause serious and irreversible damage to the upper and lower urinary tract  eg, neurological diseases like spinal cord injury, multiple sclerosis or radiation cystitis  Sometimes profound abnormalities can be found in the relative absence of symptoms Introduction UDS: Urodynamics Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

9. Urodynamics  In order to use UDS in a practical and effective way it is important that the clinician has the proper expertise to know when and why to perform a UDS study  Despite many technical advances in the recording, processing and printing of UDS studies, careful attention to technical details to assure accurate collection of data remains the cornerstone of a good study Introduction UDS: Urodynamics Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

10. Urodynamics  Since not all patients undergo UDS for the same reasons, the clinician should “customize” UDS to the patients’ symptoms and condition  That means deciding on the questions to be answered before starting each study and designing that study to obtain the answers  It is important to remember that UDS is performed in an “unnatural setting” and therefore does always duplicate real life Introduction UDS: Urodynamics Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

11. Urodynamics  A study that does not duplicate complaints or symptoms when an abnormality is recorded is not necessarily diagnostic  In addition, failure to record an abnormality does not always rule out its existence (eg, failure to demonstrate detrusor overactivity in a patient with urge incontinence) Introduction UDS: Urodynamics Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

12. Urodynamics  Functionally abnormalities of the lower urinary tract can be divided into:  Storage dysfunction (failure to properly store urine)  Emptying dysfunction (failure to empty the bladder normally)  Combined dysfunction (failure to store and empty) Functional Classification of Voiding Dysfunction Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

13. Urodynamics  Anatomically storage and emptying abnormalities can be caused by:  Bladder dysfunction  Overactive (causing failure to store)  Underactive (causing failure to empty)  Bladder outlet dysfunction  Overactive (causing failure to empty)  Underactive (causing failure to store)  Combined bladder and bladder outlet dysfunction  The urodynamic evaluation should help to determine if there is bladder or bladder outlet dysfunction (or both) and whether there is a storage and/or emptying problem Functional Classification of Voiding Dysfunction Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010: Chapter 10: 283-298

14. Urodynamics  Post-void Residual (PVR)  Excellent assessment of bladder emptying  It can be performed by ultrasound (bladder scan) or catheterization  Elevation of PVR indicates a problem with emptying, but does not tell why.  Uroflowmetry  This is also an assessment of bladder emptying.  Normal uroflow is a bell-shaped curve  When the flow rate is reduced or the pattern is altered, this could indicate bladder (underactive) or bladder outlet (obstruction) dysfunction. Simple Tests Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

15. Urodynamics  The cystometrogram (CMG) can measure filling pressure, sensation, involuntary contractions, compliance, and capacity  Sensation is the part of cystometry that is subjective and requires an alert and attentive patient and clinician The Urodynamic Test Urodynamics: Filling and Storage Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

16. Urodynamics  There are several subjective parameters that can be recorded during filling that are recognized by the International Continence Society (ICS):  First sensation of bladder filling  First aware of bladder filling  First desire to void  Feeling that would lead patient to pass urine at next convenient moment, but voiding can be delayed if necessary  Strong desire to void  Persistent desire to void without fear of leakage.  Urgency  Sudden compelling desire to void The Urodynamic Test Urodynamics: Filling and Storage Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

17. Urodynamics The Urodynamic Test Urodynamics: Filling and Storage Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

18. Urodynamics  The simultaneous measurement of abdominal pressure (Pabd), usually by a rectal or vaginal catheter and vesical pressure (Pves) during urodynamics  provides a means of calculating the true detrusor pressure (Pdet) by subtracting abdominal Pabd from Pves The Urodynamic Test Urodynamics: Filling and Storage Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

19. Urodynamics  The ability to calculate subtracted detrusor pressure allows one to distinguish between a true rise in detrusor pressure  either via a contraction or loss of compliance) and the effect of increased abdominal pressure (eg, straining, Valsalva)  This is important when rises in detrusor pressure are small or when they are accompanied by changes in abdominal pressure The Urodynamic Test Urodynamics: Filling and Storage Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

20. Urodynamics  Total vesical pressure and intra abdominal pressure The Urodynamic Test Urodynamics: Filling and Storage CMG Multichannel Urodynamics Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

21. Urodynamics  Detrusor overactivity (DO) is a urodynamic observation characterized by involuntary IDCs during the filling phase which may be spontaneous or provoked  According to the ICS, DO may be further characterized as  neurogenic DO which means it is associated with a relevant neurological condition (eg, spinal cord injury, multiple sclerosis)  or idiopathic DO which means that there is “no defined cause” (non-neurogenic) The Urodynamic Test Abnormalities of Bladder Filling: Detrusor Overactivity and Impaired Compliance Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

22. Urodynamics  The vesicoelastic properties of the bladder, based on its composition of smooth muscle, collagen, and elastin, normally produces a highly compliant structure  as the bladder fills there is little change in pressure  ICS recommends 2 standard points:  the Pdet at start of bladder filling (usually zero)  and the Pdet at cystometric capacity or before the start of any detrusor contraction that results in significant leakage The Urodynamic Test Abnormalities of Bladder Filling: Detrusor Overactivity and Impaired Compliance Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

23. Urodynamics The Urodynamic Test Abnormalities of Bladder Filling: Detrusor Overactivity and Impaired Compliance  Detrusor overactivity  This UDS tracing depicts DO. Note the 2 IDCs (arrows)  There is a rise in Pves with no associated rise in Pabd and therefore the subtracted Pdet looks identical to the Pves Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

24. Urodynamics The Urodynamic Test Abnormalities of Bladder Filling: Detrusor Overactivity and Impaired Compliance  Impaired compliance with elevated storage pressures is a urodynamic risk factor  and usually needs to be treated to prevent renal damage Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

25. Urodynamics The Urodynamic Test Abnormalities of Bladder Filling: Detrusor Overactivity and Impaired Compliance  UDS representation of impaired compliance  Note the rise in Pves (and Pdet) with bladder filling  The Pdet at the end of filling is approximately 45 cmH 2 O, which is a potentially dangerous situation Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

26. Urodynamics The Urodynamic Test Leak Point Pressures  There are 2 distinct types of leak point pressures that can be measured in the incontinent patient  The two are independent of each other and measure completely different things  The first is the abdominal leak point pressure (ALPP)  a measure of sphincter strength or the ability of the sphincter to resist changes in abdominal pressure Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

27. Urodynamics The Urodynamic Test Leak Point Pressures  ALPP is the intravesical pressure at which urine leakage occurs  due to increased abdominal pressure in the absence of a detrusor contraction  The lower the ALPP, the weaker the sphincter  There is no normal ALPP, as patients without stress incontinence will not leak at any physiologic abdominal pressure Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298 ALPP: Abdominal leak point pressure

28. Urodynamics The Urodynamic Test Leak Point Pressures  Leak point pressure Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298 ALPP: Abdominal leak point pressure

29. Urodynamics The Urodynamic Test Leak Point Pressures  ALPP <60 cm H 2 O signifies ISD  ALPP between 60-90 cm H 2 O is equivocal (there is a component of ISD)  ALPP >90 cm H 2 O indicates little or no ISD ALPP: Abdominal leak point pressure; ISD: Intrinsic sphincter deficiency Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

30. Urodynamics The Urodynamic Test Leak Point Pressures  The second type is the detrusor leak point pressure (DLPP)  a measure of detrusor pressure in patients with decreased bladder compliance  It is defined as the lowest detrusor pressure at which urine leakage occurs  in the absence of either a detrusor contraction or increased abdominal pressure Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

31. Urodynamics The Urodynamic Test Leak Point Pressures  The DLPP measures the injured bladder response to increased outlet resistance  The higher the resistance (eg, detrusor- external sphincter dyssynergia), the higher the DLPP, which is potentially dangerous to the upper tracts DLPP: Detrusor leak point pressure Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

32. Urodynamics The Urodynamic Test Leak Point Pressures  Pressure in the bladder will continue to increase as the bladder fills Leakage at arrow = DLPP = 45 cmH 2 O DLPP: Detrusor leak point pressure Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

33. Urodynamics The Urodynamic Test Urethral Pressure Profilometry  The urethral pressure profile (UPP) represents the intraluminal pressure along the length of the urethra in graphic form Urethral closure pressure profile (UCP) Is given by the subtraction of intravesical pressure fromurethral pressure Maximum urethral pressure (MUP) is the highest Pressure measured along the UPP Maximum urethral closure pressure (MUCP) is the maximum difference between the urethral pressure and the intravesical pressure Functional profile length is the length of the urethra along which the urethral pressure exceeds intravesical pressure in women Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

34. Urodynamics The Urodynamic Test Urethral Pressure Profilometry  There are no urethral pressure measurements that:  discriminate urethral incompetence from other disorders  provide a measure of the severity of the condition  provide a reliable indicator to surgical success, and return to normal after surgical intervention Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

35. Urodynamics The Urodynamic Test  Stress-induced Detrusor Overactivity  Sometimes detrusor overactivity can be triggered by a rise in abdominal pressure  The symptom may appear to be stress incontinence  but the condition causing the symptom is an involuntary contraction  not sphincteric weakness  Occult Stress Incontinence  Stress incontinence is demonstrated in a clinically continent woman with pelvic prolapse only when the prolapse is reduced Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

36. Urodynamics The Urodynamic Test Urodynamics: Emptying – The Voiding Phase  Normal voiding accomplished by activation of micturition reflex, which involves:  Relaxation of striated urethral sphincter  Contraction of detrusor muscle  Opening of vesical neck and urethra  Onset of urine flow Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

37. Urodynamics The Urodynamic Test Urodynamics: Emptying – The Voiding Phase  UDS can evaluate several parameters during the voiding phase including: Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298 Detrusor contractility Relaxation of the bladder outlet Coordination of sphincters

38. Urodynamics The Urodynamic Test Urodynamics: Emptying – The Voiding Phase  The Pressure Flow Relation  In males, obstruction has been defined based on the model of benign prostatic obstruction (BPO)  The ICS nomogram is the one most commonly used today  Using this nomogram and the bladder outlet obstruction index (BOOI) derived from it, men can be divided into three groups  obstructed, equivocal and unobstructed Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

39. Urodynamics The Urodynamic Test Urodynamics: Emptying – The Voiding Phase  ICS nomogram BOOI = PdetQmax – 2(Qmax ) Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

40. Urodynamics The Urodynamic Test Urodynamics: Emptying – The Voiding Phase  Obstruction in women cannot be defined by the ICS nomogramor the BOOI as these will underestimate female BOO  Women void at much lower pressures than men and the obstructed female bladder outlet may not respond as dramatically (or at least with the same pressures) as in the male Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298 BOOI: Bladder outlet obstruction index

41. Urodynamics The Urodynamic Test Urodynamics: Emptying – The Voiding Phase  Sphincter Coordination  Normal voiding requires external sphincter relaxation followed by contraction of the detrusor  The external sphincter (and internal sphincter) should remain relaxed until voiding is complete  The rise in detrusor pressure is preceded by a fall in urethral pressure and relaxation of the external sphincter as measured by electromyography (EMG) Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

42. Urodynamics The Urodynamic Test Urodynamics: Emptying – The Voiding Phase  Sphincter Coordination Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

43. Urodynamics The Urodynamic Test Urodynamics: Emptying – The Voiding Phase  Normally EMG activity decreases before a voluntary bladder contraction  however it is not abnormal for EMG activity to increase with an involuntary contraction as part of a guarding reflex to inhibit the IDC Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298 EMG: Electromyography

44. Urodynamics The Urodynamic Test Urodynamics: Emptying – The Voiding Phase  Not abnormal for EMG activity to increase with involuntary contraction as part of guarding reflex inhibiting IDC Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

45. Urodynamics The Urodynamic Test Urodynamics: Emptying – The Voiding Phase  Detrusor-external sphincter dyssynergia (DESD) occurs  when there is an involuntary increase external sphincter associated with DO and also with voiding  It is caused by a neurological lesion in the suprasacral spinal cord  DESD can produce profound changes as the detrusor involuntarily contracts against a relatively closed sphincter Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

46. Urodynamics The Urodynamic Test Urodynamics: Emptying – The Voiding Phase  This will result in high pressures and can even cause impaired bladder compliance over time  DESD is considered a urodynamic risk factor for upper tract deterioration Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

47. Urodynamics The Urodynamic Test Urodynamics: Emptying – The Voiding Phase  UDS tracing of a patient with myelodysplasia and neurogenic DO and DESD  Note the initial IDC associated with DESD and incontinence (measured on the flow channel)  With refilling, the UDS is again DO with DESD and then the patient is told to voluntarily void and there is persistent increased EMG activity  As a result there is high pressure, low flow voiding (obstruction from the dyssynergic sphincter Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298 DESD: Detrusor-external sphincter dyssynergia; DO: Detrusor overactivity; IDC: iIvoluntary Detrusor Contractions

48. Urodynamics Videourodynamics  Videourodynamics (VUDS) consists of the simultaneous measurement of UDS parameters and imaging of the lower urinary tract  provides the most precise evaluation of voiding function and dysfunction  VUDS is useful when an anatomic picture is desired:  In cases of known or suspected anatomical abnormality  Failure to demonstrate incontinence by conventional methods  Evaluation of bladder neck (internal sphincter) synergy  Neurological diseases (or other potentially dangerous causes of voiding dysfunction) where there is associated vesicoureteral reflux  In such cases, reflux volumes and pressures can be measured Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298

49. Urodynamics Videourodynamics  VUDS study of a 45-year-old male with LUTS including frequency, urgency and decreased force of stream Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298 LUTS: Lower Urinary Tract Symptoms

50. Urodynamics Videourodynamics  VUDS study of a male with a C1-2 spinal cord injury with suspected DESD and retention of urine, being considered for external sphincterotomy Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298 DESD: Detrusor-external sphincter dyssynergia

51. Urodynamics Urodynamic Risk Factors  It cannot be emphasized enough that certain UDS findings are potentially dangerous and usually require intervention  Impaired compliance  DESD  DISD  High pressure DO present throughout filling  Elevated DLPP (>40 cm H 2 O)  Poor emptying with high storage pressures Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in Urology. 2 nd Edition 2010; Chapter 10: 283-298 DESD: Detrusor-external sphincter dyssynergia; DO: Detrusor overactivity