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Urodynamic Study in Lower Urinary Tract Dysfunction

Hann-Chorng Kuo

Department of Urology

Buddhist Tzu Chi General Hospital


Lower Urinary Tract Symptoms Storage symptoms

Frequency, Urgency, Nocturia

Incontinence

Suprapubic fullness and pain Empty symptoms

Hesitancy, Intermittency, Small caliber,

Dysuria, Residual urine sensation


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


Bladder Diary


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


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


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


Urodynamic study- Upper urinary tract & Special tests Whitaker test (upper tract pressure flow stu

dy) Ice water test Urecholine test Rapid cystometrography Potassium chloride test Other pharmacological test


Why Urodynamics? To obtain information of urinary tract funct

ion and dysfunction To confirm clinical diagnosis To compare treatment results To investigate pathophysiology of urinary t

ract diseases


Uroflowmetry – Normal flow


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)


Uroflowmetry – Parameters


Abnormal Flow Pattern Very high initial Qmax: detrusor instability

without BOO Obstructive flow pattern: compressive,cons

trictive flow pattern Intermittent and straining pattern Saw-teeth flow pattern Terminal dribbling pattern


Uroflowmetry – Intermittent flow


Uroflowmetry – Straining flow


Uroflowmetry – Low contractility


Uroflowmetry – Obstructive flow


Pitfalls of Flow Interpretation Qmax is variable between several voids 7% of mean with LUTS and high Qmax mi

ght have bladder outlet obstruction Women with detrusor areflexia can have g

ood Qmax by abdominal straining Embarrassment during examination can gre

atly influence Qmax expression


Cystometrography Measuring intravesical pressure (Pves) duri

ng 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


Cystometry - technique


Cystometrography Bladder sensation: FSF, FS, US,capacity Bladder compliance Detrusor pressure at end-filling stage Voiding pressure: Men < 50 cmH2O, Wom

en <35cmH2O

Coordination of external sphincter EMG


Normal Cystometrogram Resting pressure < 10 cm water FSF at 100-200ml, FS at 300-400 ml Cystometric capacity at 400-500 ml Voiding pressure < 50 cm water in men an

d <35 cm water in women A coordinated sphincter EMG activity


Cystometry- Neurogenic detrusor overactivity and DESD


Cystometry- Idiopathic detrusor overactivity


Cystometry- after contraction


Bladder sensation Increased sensation with rapid filling, cold

infusion, catheter placement, psychological Low detrusor contractility due to smaller bl

adder filling volume Vague bladder sensation from peritoneal su

rface in patients with detrusor areflexia Patient used abdominal straining to void


Bladder Compliance Compliance is related to filling rate Low compliance always combines with lo

w contractility and large residuum Upper tract deterioration is associated with

low bladder compliance A detrusor leak-point pressure >40 cm wat

er might endanger upper tract


Poor Bladder Compliance and Stress Urinary Incontinence


Detrusor areflexia and Detrusor underactivity DA is limited to neuropathy Detrusor underactivity: low detrusor pressu

re with low flow rate and large residual urine

DHIC: detrusor instability (hyperreflexia) and inadequate contractility

Psychological embarrassment


Pressure Flow Study Measuring detrusor pressure, flow rate, EM

G activity during voiding phase Concomitant recording of intra-abdominal

pressure Calculation of resistance relation of P & Q Calculation of Abrams-Griffiths number: A

G number = Pdet – 2 x Qmax


Pressure flow study - Technique


Multi-channel Pressure Flow Study


Relationship of Pressure & Flow


Pressure flow study – DHIC


Pressure flow study–Cystocele and BOO in woman


Low contractility & low flow


Detrusor overactivity & voluntary PFM contraction


Detrusor overactivity in Storage phase


Detrusor overactivity in a contracted bladder


Provoked DI in storage phase


Urethral Pressure Profilometry Measuring Intra-urethral resistance by perf

usion technique or microtip transducer A static pressure measurement, but cannot

predicting voiding efficiency Dynamic UPP Academic purpose and assessment of thera

peutic results


Urethral Pressure Profilometry


Stress UPP in Continent woman


Stress UPP in Incontinent woman


Nitric oxide UPP in Neuropathic bladder


Voluntary Pelvic floor contraction


Leak-point Pressures Measuring the increased intravesical or intr

a-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


Abdominal Leak point pressure in Type I SUI


Abdominal leak point pressure in Type II SUI


Cough vs Valsalva LPP in Type II/III SUI


Cough vs Valsalva LPP in Pure Type III SUI


LPP – Intravesical vs intra-abdominal recording


Valsalva LPP in Cystocele & SUI


Videourodynamic Study Combined image and pressure flow study i

n 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 expre

ssion during investigation


Clinical Application of Videourodynamics in LUTS Differential diagnosis of BOO Identify types of stress incontinence Confirm bladder neck dysfunction and DE

SD in neuropathic voiding dysfunction Upper tract dynamics and determine site of

obstruction Analysis of pathophysiology of LUTS


Videourodynamic study in DI


Videourodynamic study in Female urethral stricture


Mixed DI and SUI


Poor relaxation of urethral sphincter


Low pressure and BOO


Dysfunctional voiding in woman with urge incontinence


Videourodynamic study in SUI


Videourodynamic study in SUI after Pubovaginal sling


Videourodynamics in Post-incontinence surgery BOO

排尿障礙治療中心 版權所有 urodynamic study in lower urinary tract dysfunction...

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排尿障礙治療中心版權所有 urodynamic study in lower urinary tract dysfunction...