An Overview of Urodynamic An Overview of Urodynamic StudiesStudies

Saleh BinsalehSaleh Binsaleh

Introduction

Urodynamics is the general term for the Urodynamics is the general term for the study of the storage and voiding study of the storage and voiding function/dysfunction of the lower urinary function/dysfunction of the lower urinary tract.tract.

It is crucial that the UDS reproduce the It is crucial that the UDS reproduce the patient’s presenting symptoms.patient’s presenting symptoms.

UDS Armamentarium

cystometrycystometry uroflowmetryuroflowmetry Urethral pressure studiesUrethral pressure studies Pressure-flow micturation studiesPressure-flow micturation studies Video-urodynamic studiesVideo-urodynamic studies Electrophysiologic studiesElectrophysiologic studies

Indications

Incontenance:Incontenance:-recurrent incontenance in whome surgery is -recurrent incontenance in whome surgery is

planned.planned.-mixed urge and stress symptoms.-mixed urge and stress symptoms.-associated voiding problems-associated voiding problems-pt with neurologic disorders-pt with neurologic disorders-pt with mismatch between signs and -pt with mismatch between signs and

symptoms.symptoms.

Indications(cont.)

Outflow Obstruction:Outflow Obstruction:-pt with LUTS, at least uroflow study.-pt with LUTS, at least uroflow study. Neurogenic bladder:Neurogenic bladder:-all neurologically impaired patients with neurogenic -all neurologically impaired patients with neurogenic

bladder dysfunction.bladder dysfunction. Children with voiding dysfunction:Children with voiding dysfunction:-kids with daytime urgency and urge -kids with daytime urgency and urge

incontenance,recurrent infection,reflux,or upper incontenance,recurrent infection,reflux,or upper tract changes.tract changes.

Clinical roles

Characterization of detrusor functionCharacterization of detrusor function evaluation of bladder outletevaluation of bladder outlet evaluation of voiding functionevaluation of voiding function diagnosis and characterization of diagnosis and characterization of

neuropathy.neuropathy.

Patient preparation and precautions

Prior to UDSPrior to UDS A working Dx should be entertainedA working Dx should be entertained hx and physicalhx and physical 3-day voiding diary3-day voiding diary certain drugs should be heldcertain drugs should be held

UDS should be deferred in the presence ofUDS should be deferred in the presence of UTIUTI recent instrumentation (cystoscopy)recent instrumentation (cystoscopy)

Routine prophylactic abx not necessary.Routine prophylactic abx not necessary. High risk pts (cardiac valve,orthopedic prosthesis,GU High risk pts (cardiac valve,orthopedic prosthesis,GU

prosthesis,pacemakers) parental antibiotic prophylaxis might be prosthesis,pacemakers) parental antibiotic prophylaxis might be necessary.necessary.

Patient preparation and precautions(cont.) Pt who are catheter dependent idealy should have Pt who are catheter dependent idealy should have

the catheter removed and be placed on CIC for a the catheter removed and be placed on CIC for a period before UDS performed.period before UDS performed.

The test should be done in private area,as few The test should be done in private area,as few observers as possible.observers as possible.

In neuropathic pts, one must be cautious of In neuropathic pts, one must be cautious of autonomic dysreflexia.if the symptoms occur then autonomic dysreflexia.if the symptoms occur then the bladder should be emptied immediately and the bladder should be emptied immediately and antihypertensive drug (nifedipine,hydralazine) antihypertensive drug (nifedipine,hydralazine) might need to be given.might need to be given.

Cystometry

Measurement of intravesical bladder pressure Measurement of intravesical bladder pressure during bladder filling.during bladder filling.

bladder access by transurethral catheter, or rarely bladder access by transurethral catheter, or rarely by percutaneous s/p tube.by percutaneous s/p tube.

filling medium either gas (COfilling medium either gas (CO22) or liquid ) or liquid (water, saline, or contrast material at body temp).(water, saline, or contrast material at body temp).

liquid cystometry is more physiologic.liquid cystometry is more physiologic. ideally, filling should be performed in standing ideally, filling should be performed in standing

position.position.

Cystometry(cont.) Bladder filling either by diuresis or filling through a catheter.Bladder filling either by diuresis or filling through a catheter. fillingfilling

slow (up to 10 ml/min), physiologicslow (up to 10 ml/min), physiologic medium (10 to 100 ml/min)medium (10 to 100 ml/min) fast ( > 100 ml/min)fast ( > 100 ml/min)

children and pts with known bladder hyperactivity require children and pts with known bladder hyperactivity require slow fill rates.slow fill rates.

The reference point is the superior edge of the symphysis The reference point is the superior edge of the symphysis pubis.pubis.

All systems should be zeroed to atmospheric pressure.All systems should be zeroed to atmospheric pressure. No air bubbles.No air bubbles.

Cystometry(cont.)

Single Vs multi-channel UDS:Single Vs multi-channel UDS:

-single: Pves only-single: Pves only

-multi: Pves, Pdet, Pabd-multi: Pves, Pdet, Pabd Provocative maneuvers:Provocative maneuvers:

- to unmask abnormalities of detrusor function(UC)- to unmask abnormalities of detrusor function(UC)

- fast fill cystometry, posture change(erect), - fast fill cystometry, posture change(erect), coughing, jumping.coughing, jumping.

Phases of cystometrogramPhases of cystometrogram

Cystometry(cont.)

Measurements via cystometry:Measurements via cystometry:- bladder capacitybladder capacity- SensationSensation- ComplianceCompliance- Detrusor stabilityDetrusor stability

Cystometry(cont.)

Measurements via cystometryMeasurements via cystometry bladder capacitybladder capacity, volume at which a patient with normal , volume at which a patient with normal

sensation feels that micturition can no longer be delayed.sensation feels that micturition can no longer be delayed.-normal=400-500ml. Can’t be determined in pts with -normal=400-500ml. Can’t be determined in pts with

impaired sensation.impaired sensation.- maximal bladder capacity,functional bladder - maximal bladder capacity,functional bladder

capacity,anesthetic bladder capacity.capacity,anesthetic bladder capacity. sensationsensation, first ,normal,strong desire to void,urgency,pain., first ,normal,strong desire to void,urgency,pain. bladder compliancebladder compliance, change in detrusor pressure over a , change in detrusor pressure over a

given change in volume.given change in volume.

Cystometry(cont.)

Compliance:Compliance:- normal bladder is highly compliant,and can hold normal bladder is highly compliant,and can hold

large volumes at low pressure.large volumes at low pressure.- Normal pressure rise during the course of CMG in Normal pressure rise during the course of CMG in

normal bladder will be only 6-10 cmH2o.normal bladder will be only 6-10 cmH2o.- Decrease compliance = Decrease compliance = >> 20 ml/cmH2o, poorly 20 ml/cmH2o, poorly

distensible bladder.distensible bladder.- Increase compliance. Increase compliance.

Cystometry(cont.)- - Leak point pressures:Leak point pressures:

*Detrusor LPP*Detrusor LPP, the lowest bladder pressure where urethral leak , the lowest bladder pressure where urethral leak of urine is first identified (risk with > 40cm Hof urine is first identified (risk with > 40cm H22O).O).

**Valsalva LPPValsalva LPP,the pressure that causes leakage of urine in the ,the pressure that causes leakage of urine in the absence of bladder contraction.(using valsalva absence of bladder contraction.(using valsalva maneuver,cough. If there is no leakage at high maneuver,cough. If there is no leakage at high pressures(pressures(<<150cmH2O) then the urethera is unlikely to be the 150cmH2O) then the urethera is unlikely to be the cause of the pt’s incontinence,and rather the bladder is the cause of the pt’s incontinence,and rather the bladder is the more likely cause.more likely cause.

VLLPVLLP>>60 cm H60 cm H22O: significant ISDO: significant ISD

VLLP 60-90 cm HVLLP 60-90 cm H22O :equivocalO :equivocal

VLLPVLLP<<90 cm H90 cm H22O : urethral hypermobilityO : urethral hypermobility

Cystometry(cont.) Involuntary contractions:Involuntary contractions:- detrusor stability,detrusor stability, reflects the integrity of central reflects the integrity of central

nervous system control over bladder function.nervous system control over bladder function.- Unstable bladder,Unstable bladder,contract either spontaneously or with contract either spontaneously or with

provocative maneuvers during filling cystometry, while provocative maneuvers during filling cystometry, while pt is trying to inhibit micturation.it is any involuntary pt is trying to inhibit micturation.it is any involuntary pressure rise that is associated with urgency.pressure rise that is associated with urgency.

- Detrusor hyperreflexia: Detrusor hyperreflexia: in pt with neurologic disease.in pt with neurologic disease.- Detrusor instability:Detrusor instability: in absence of neurologic disease. in absence of neurologic disease.

Cystometry(cont.)

Involuntary contractions:Involuntary contractions: hyperactive bladderhyperactive bladder is one that demonstrates is one that demonstrates

instability, hyperreflexia, or low compliance.instability, hyperreflexia, or low compliance. motor urge incontinencemotor urge incontinence, pts with urgency and urge , pts with urgency and urge

incontinence in whom unstable detrusor contractions incontinence in whom unstable detrusor contractions can be demonstrated on UDScan be demonstrated on UDS

sensory urgencysensory urgency, pts in whom the same symptoms are , pts in whom the same symptoms are present but have a stable bladder on UDS.present but have a stable bladder on UDS.

*ambulatory monitoring has confirmed the presence of *ambulatory monitoring has confirmed the presence of unstable bladder contractions in up to 69% of normal unstable bladder contractions in up to 69% of normal volunteers.volunteers.

Cystometry(cont.)

factors that may alter the CMGfactors that may alter the CMG include an include an incompetent outlet, massive reflux, rapid fill, incompetent outlet, massive reflux, rapid fill, lack of pt cooperation, and substances irritative lack of pt cooperation, and substances irritative to bladder.to bladder.

Cystometry(cont.)

Normal CMG:Normal CMG:- capacity 400-500mlcapacity 400-500ml- Constant low pressure that does not reach Constant low pressure that does not reach

more than 6-10 cmH2o above baseline at more than 6-10 cmH2o above baseline at the end of filling.the end of filling.

- Provocative maneuvers should not provoke Provocative maneuvers should not provoke a bladder contraction normally.a bladder contraction normally.

Cystometry(cont.)Pharmacologic tests: Bethanechol supersensitivity test:Bethanechol supersensitivity test:

an attempt to distinguish between a neurogenic and a an attempt to distinguish between a neurogenic and a myogenic origin in pt with an acontractile bladder.myogenic origin in pt with an acontractile bladder.

Denervated bladder develops hypersensitivity to the Denervated bladder develops hypersensitivity to the normal excitatory neurotransmitters.normal excitatory neurotransmitters.

end-fill pressure obtained after infusion of liquid at 1ml/s end-fill pressure obtained after infusion of liquid at 1ml/s to a volume of 100cc( to determine average end-fill to a volume of 100cc( to determine average end-fill pressure)pressure)

after this, 0.035mg/kg of bethanechol chloride is injected after this, 0.035mg/kg of bethanechol chloride is injected s/c.s/c.

denervated bladder shows an increase in pressure of denervated bladder shows an increase in pressure of >15cm H2O above baseline.>15cm H2O above baseline.

Pharmacologic tests(cont.)

- positive test suggest an interruption in the positive test suggest an interruption in the afferent or efferent peripheral or distal afferent or efferent peripheral or distal spinal innervations of the bladder.spinal innervations of the bladder.

- However, the test shown to be unreliable However, the test shown to be unreliable (76% sensitive,50% specific) for (76% sensitive,50% specific) for neurogenic bladder.neurogenic bladder.

Pharmacologic tests(cont.) Ice water test:Ice water test:- Differentiate upper from lower motor neuron lesions.- Differentiate upper from lower motor neuron lesions.- Based on the principle that mucosal temperature receptors can - Based on the principle that mucosal temperature receptors can

elicit a spinal reflex contraction of the detrusor, normally elicit a spinal reflex contraction of the detrusor, normally inhibited by supraspinal centers, which is interrupted in inhibited by supraspinal centers, which is interrupted in UMNL.UMNL.

- rapid injection of the bladder with ice water.- rapid injection of the bladder with ice water.- fluid is left for 1 min.- fluid is left for 1 min.- if sustained bladder contraction and fluid is expelled during this - if sustained bladder contraction and fluid is expelled during this

period, or increase intravesical pressure, test is +ve.period, or increase intravesical pressure, test is +ve.- +ve test in 91-97% of suprasacral lesions; it is almost never +ve - +ve test in 91-97% of suprasacral lesions; it is almost never +ve

in LMN lesions.in LMN lesions.

Uroflowmetry Non invasive studyNon invasive study An estimate of effectiveness of the act of voiding along with An estimate of effectiveness of the act of voiding along with

PVR.PVR. Influenced byInfluenced by

effectiveness of detrusor contractioneffectiveness of detrusor contraction completeness of sphincteric relaxationcompleteness of sphincteric relaxation patency of the urethrapatency of the urethra

3 methods used3 methods used gravimetric gravimetric rotating diskrotating disk electronic dipstickelectronic dipstick

Uroflowmetry(cont.)

Recorded variables during uroflowmetry study:Recorded variables during uroflowmetry study:-flow pattern-flow pattern-voided volume-voided volume-maximum flow rate(Q max)-maximum flow rate(Q max)-flow time-flow time-average flow rate(Q mean)-average flow rate(Q mean)-time to maximum flow-time to maximum flow-voiding time-voiding time-hesitancy-hesitancy

Uroflowmetry(cont.)

Optimal voids 200 to 400ccOptimal voids 200 to 400cc voids < 150cc are difficult to interpret.voids < 150cc are difficult to interpret. Pt should be well hydrated with full bladder, but Pt should be well hydrated with full bladder, but

not overly distended bladder.not overly distended bladder. study should be performed in privacy and pt study should be performed in privacy and pt

encouraged to void in his normal fashion.encouraged to void in his normal fashion. voided volume, pt’s position, method of bladder voided volume, pt’s position, method of bladder

filling, and type of fluid should be recorded.filling, and type of fluid should be recorded.

Uroflowmetry(cont.)

max flow rate and shape of curve may max flow rate and shape of curve may produce more reliable indicators of BOOproduce more reliable indicators of BOO

Q max is the most reliable variable in Q max is the most reliable variable in detecting abnormal voiding,and influenced detecting abnormal voiding,and influenced by several factors:by several factors:

-age & sex: decreases with age in men.-age & sex: decreases with age in men.-chance: multiple trials increases accuracy.-chance: multiple trials increases accuracy.-volume of voided urine: 150 cc or more.-volume of voided urine: 150 cc or more.

Uroflowmetry(cont.)

Uroflow and BOO:Uroflow and BOO:

-in general the test alone is insufficient to diagnose in general the test alone is insufficient to diagnose BOO.BOO.

-McLoughlin (1990) demonstrated that Qmax < -McLoughlin (1990) demonstrated that Qmax < 12cc/s was a good indicator for obstruction.12cc/s was a good indicator for obstruction.

-concept of high flow obstruction:-concept of high flow obstruction:

Qmax Qmax << 15ml/sec,detrusor pressure 15ml/sec,detrusor pressure< < 100cmH2O in 100cmH2O in symptomatic patient.symptomatic patient.

Residual urine volume

It integrates the activity of the bladder and the It integrates the activity of the bladder and the outlet during emptying.outlet during emptying.

Can be measured directly by bladder Can be measured directly by bladder catheterization, or estimated by usscatheterization, or estimated by uss

What is considered a normal PVR is controversial.What is considered a normal PVR is controversial.- in adults a value less than 25ml is considered in adults a value less than 25ml is considered

normal , and PVR normal , and PVR << 100 warrant carefull 100 warrant carefull surveillance and/or treatment.surveillance and/or treatment.

- A PVR A PVR <<100 ml in elderly may under certain 100 ml in elderly may under certain circumstances be considered acceptable.circumstances be considered acceptable.

Urethral pressure profilometry

Static urethral pressure profile. (at rest)Static urethral pressure profile. (at rest) stress urethral pressure profile. ( during stress urethral pressure profile. ( during

straining)straining) Micturational urethral pressure profile. Micturational urethral pressure profile.

(during voiding)(during voiding) valsalva LPP.valsalva LPP.

Urethral pressure profilometry

UPP is recording of intraluminal pressure along UPP is recording of intraluminal pressure along length of urethralength of urethra

study performed during slow retraction of a study performed during slow retraction of a catheter with side holes (0.5mm/s) catheter with side holes (0.5mm/s)

bladder pressure should be measured bladder pressure should be measured simultaneously to exclude effects of an associated simultaneously to exclude effects of an associated detrusor contractiondetrusor contraction

static UPPstatic UPP: cannot diagnose stress urinary : cannot diagnose stress urinary incontinence, sphincter dyssynergia, or BOO. It is incontinence, sphincter dyssynergia, or BOO. It is not a functional test.not a functional test.

Urethral pressure profilometry

Stress UPP:Stress UPP:- Monitor urethral pressure and bladder - Monitor urethral pressure and bladder

pressure simultaneouslypressure simultaneously- performed as the profile catheter is - performed as the profile catheter is

withdrawn along the urethra during periods withdrawn along the urethra during periods of intermittent stress (cough)of intermittent stress (cough)

- technically difficult to perform, and - technically difficult to perform, and movement artifact of catheter is commonmovement artifact of catheter is common

Urethral pressure profilometry Micturational UPP:Micturational UPP:- To evaluate the bladder outlet.- To evaluate the bladder outlet.- same as the standard UPP, only the pt voids while the catheter - same as the standard UPP, only the pt voids while the catheter

is being withdrawn.is being withdrawn.- during voiding, bladder and urethral pressures are identical.- during voiding, bladder and urethral pressures are identical.- if obstruction exists in urethra, the intraurethral pressure distal - if obstruction exists in urethra, the intraurethral pressure distal

to obstruction is less than that within bladder or proximal to to obstruction is less than that within bladder or proximal to obstruction, thus when a significant pressure drop is obstruction, thus when a significant pressure drop is encountered on withdrawal, this corresponds to the site of encountered on withdrawal, this corresponds to the site of obstruction.obstruction.

- however, distortion artifacts are considerable and location of - however, distortion artifacts are considerable and location of catheter is inexact.catheter is inexact.

Pressure-Flow Micturition Studies Simultaneous measurement of bladder pressure and flow Simultaneous measurement of bladder pressure and flow

rate throughout the micturation cycle.rate throughout the micturation cycle. The best method of quantitatively analyzing voiding The best method of quantitatively analyzing voiding

function.function. Access to bladder via transurethral or s/p.Access to bladder via transurethral or s/p. catheter larger than 8 Fr may obstruct and affect pressure catheter larger than 8 Fr may obstruct and affect pressure

flow recordings.ideally size should be 8F or less.flow recordings.ideally size should be 8F or less. intra-abdominal pressure measured by balloon catheter in intra-abdominal pressure measured by balloon catheter in

rectum or vagina.rectum or vagina. men should void in standing position, while women men should void in standing position, while women

seated on commode.seated on commode.

PFS ( cont.)

Terminology:Terminology:

- - the detrusor opening pressurethe detrusor opening pressure::

Pdet recorded at the onset of measured flow.Pdet recorded at the onset of measured flow.

- - the detrusor pressure at maximal flowthe detrusor pressure at maximal flow::

the magnitude of micturation contraction at the time the magnitude of micturation contraction at the time when the flow rate is at its maximum.when the flow rate is at its maximum.

pressure pressure < < 100 cmH2O indicate outlet obstruction 100 cmH2O indicate outlet obstruction even if the flow rate is normal.even if the flow rate is normal.

PFS ( cont.)

Detrusor opening pressure > 80cm may indicate outflow Detrusor opening pressure > 80cm may indicate outflow obstruction.obstruction.

detrusor pressure at Qmax > 100cm implies outlet detrusor pressure at Qmax > 100cm implies outlet obstruction even if flow rate is normal.obstruction even if flow rate is normal.

No consensus regarding critical value for pressure and No consensus regarding critical value for pressure and flow that is diagnostic for obstruction.flow that is diagnostic for obstruction.

Pdet = Pves – PabdPdet = Pves – Pabd Normal male generally voids with Pdet 40-60 cmH2O, Normal male generally voids with Pdet 40-60 cmH2O,

and woman with lower pressure.and woman with lower pressure. Pdet more accurately measures bladder wall contractionsPdet more accurately measures bladder wall contractions

PFS ( cont.)

PFS ( cont.)

Indications for pressure-flow studiesIndications for pressure-flow studies::- to differentiate between pts with a low Q max sec. to differentiate between pts with a low Q max sec.

to obstruction, from those sec. To poor to obstruction, from those sec. To poor contractility.contractility.

- Identify pt with normal flow rates but high Identify pt with normal flow rates but high pressure obstruction.pressure obstruction.

PFS ( cont.)

Indications for pressure-flow studiesIndications for pressure-flow studies::- LUTS in pt with hx of neurologic disease (CVA, - LUTS in pt with hx of neurologic disease (CVA,

Parkinson’s).Parkinson’s).- LUTS with normal flow rates (Qmax > 15cc/min).- LUTS with normal flow rates (Qmax > 15cc/min).- younger men with LUTS.- younger men with LUTS.- men whom LUTS sx of bladder instability rather - men whom LUTS sx of bladder instability rather

than flow disorder.than flow disorder.- men with little endoscopic evidence of prostate - men with little endoscopic evidence of prostate

occlusion.occlusion.

PFS ( cont.)

Pressure-flow plots:Pressure-flow plots:- for PFS equivocal results.for PFS equivocal results.- Many models available.Many models available.

1- Abrams-Griffiths nomogram.1- Abrams-Griffiths nomogram.

2- Schafer method.2- Schafer method.

3- ICS provisional nomogram3- ICS provisional nomogram

PFS ( cont.)

Abrams-Griffiths nomogramAbrams-Griffiths nomogram Divides obstructed from equivocal from Divides obstructed from equivocal from

unobstructed pattern.unobstructed pattern. plot of Pplot of PdetdetQQmaxmax vs. Q vs. Qmaxmax

pts in the equivocal group, if minimum voiding pts in the equivocal group, if minimum voiding pressure is > 40 cm Hpressure is > 40 cm H22O, then obstruction is present O, then obstruction is present

grading of obstructiongrading of obstructionAG number = (PAG number = (PdetdetQQmax)max) – 2(Q – 2(Qmax)max)

Can grade the degree of obstruction before and Can grade the degree of obstruction before and after treatment.after treatment.

Schafer method

ICS provisional nomogram

Video-Urodynamics UDS with simultaneous fluoroscopic image of the lower UDS with simultaneous fluoroscopic image of the lower

urinary tract.urinary tract. Equipment and technique:Equipment and technique:- CMG + PFS same as before but the study is conducted on a - CMG + PFS same as before but the study is conducted on a

fluoroscopy table, and the filling medium is a radiographic fluoroscopy table, and the filling medium is a radiographic contrast agent.contrast agent.

clinical applicability:clinical applicability: complex BOOcomplex BOO evaluation of incontinenceevaluation of incontinence neurogenic bladder dysfunctionneurogenic bladder dysfunction identification of associated pathologyidentification of associated pathology

Video-Urodynamics

Electrophysiologic testing

Sphincter EMG studies the bioelectric potentials Sphincter EMG studies the bioelectric potentials generated in distal striated sphincter mechanism.generated in distal striated sphincter mechanism.

Two different levels:Two different levels:1-Kinesiologic studies:1-Kinesiologic studies:

examine sphincter activity during bladder filling examine sphincter activity during bladder filling and voiding.and voiding.

2-Neurophysiologic tests:2-Neurophysiologic tests: examine the integrity of innervation of the muscle.examine the integrity of innervation of the muscle. Require considerable expertise.Require considerable expertise.

Electrophysiologic testing(cont.)

Overall,the most important information Overall,the most important information obtained from sphincter EMG is whether obtained from sphincter EMG is whether there is coordination or not between the there is coordination or not between the external sphincter and the bladder. external sphincter and the bladder.

Electrophysiologic testing(cont.) Kinesiologic Studies:Kinesiologic Studies:- Signal may be recorded by surface electrodes or by - Signal may be recorded by surface electrodes or by

hooked wire electrodes introduced into the periurethral hooked wire electrodes introduced into the periurethral muscle.muscle.

- Before filling, pt asked to demonstrate volitional control - Before filling, pt asked to demonstrate volitional control of sphincter (intact pyramidal tracts).of sphincter (intact pyramidal tracts).

- Bulbocavernosus reflex is tested (intact sacral arc).- Bulbocavernosus reflex is tested (intact sacral arc).- EMG activity gradually increase during filling cystometry - EMG activity gradually increase during filling cystometry

(recruitment) and then cease and remains so for the time (recruitment) and then cease and remains so for the time of voiding.of voiding.

- Once bladder is empty, sphincter EMG activity resumes.- Once bladder is empty, sphincter EMG activity resumes.

Kinesiologic Studies(cont.)

Failure of the sphincter to relax or stay completely Failure of the sphincter to relax or stay completely relaxed during micturation is abnormal.relaxed during micturation is abnormal.

In pt with neurologic disease, this is called In pt with neurologic disease, this is called detrusor-sphincter dyssenergia.detrusor-sphincter dyssenergia.

In the absence of neurologic disease, it is called In the absence of neurologic disease, it is called pelvic floor hyperactivity,or dysfunctional pelvic floor hyperactivity,or dysfunctional voiding.voiding.

Kinesiologic studies do not diagnose neuropathy Kinesiologic studies do not diagnose neuropathy but may characterize effects of it.but may characterize effects of it.

Kinesiologic Studies(cont.)

Important role in identification of abnormal Important role in identification of abnormal sphincter activity in pts with neurogenic sphincter activity in pts with neurogenic bladder dysfunction and in those with bladder dysfunction and in those with voiding dysfunction of behavioral origin.voiding dysfunction of behavioral origin.

This study have little role to play in routine This study have little role to play in routine UDS evaluation of incontinent or obstructed UDS evaluation of incontinent or obstructed pts in whom neuropathy is not suggested by pts in whom neuropathy is not suggested by other clinical findings.other clinical findings.

Neurophysiologic Recordings To diagnose and characterize the presence of neuropathy or To diagnose and characterize the presence of neuropathy or

myopathy.myopathy. special needle inserted directly into the muscle to be tested.special needle inserted directly into the muscle to be tested. motor unit action potentials (MUAP) in health and disease motor unit action potentials (MUAP) in health and disease

differ.differ. Normal distal urethral sphincter muscle has a biphasic or Normal distal urethral sphincter muscle has a biphasic or

triphasic wave form,but denervated muscle has polyphasic triphasic wave form,but denervated muscle has polyphasic potentials.potentials.

MUAP studies find their role in evaluation of pt with MUAP studies find their role in evaluation of pt with bladder dysfunction of unknown cause in whom bladder dysfunction of unknown cause in whom neuropathy is suspected.neuropathy is suspected.

Nerve Conduction Studies

Stimulation of a peripheral nerve and monitoring Stimulation of a peripheral nerve and monitoring of time taken for a response to occur in its of time taken for a response to occur in its innervated muscle.innervated muscle.

Latency: is the time from stimulation till response.Latency: is the time from stimulation till response. A test of the integrity of reflex arc.A test of the integrity of reflex arc. Pt with suprasacral lesions may have normal or Pt with suprasacral lesions may have normal or

low latencies(26-30 msec.)low latencies(26-30 msec.) Example: bulbocavernous reflex latency.Example: bulbocavernous reflex latency.

Thanks