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Investigations of Female Lower
Urinary Tract Symptoms
(F – LUTS)
Dr Ismaiel Abu Mahfouz
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Investigations
Advanced
• Urodynamic studies
• Surface Electromyography
• Urethral pressure profilometry
• Imaging studies
• Cystourethroscopy
Basic
• Urine test
• Bladder diary
• Pad test
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Basic investigations
• Urine test
• Bladder diary
• The Pad test
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Urine test
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The Bladder Diary
• Daytime urinary frequency
• Nocturnal frequency/nocturia
• Twenty-four-hour frequency
• Twenty-four-hour urine production
• Maximum voided volume
• Average voided volume
• Median functional bladder
• Polyuria: (> 40 ml/kg in during 24 hr or 2.8 L)
• Nocturnal urine volume
• Nocturnal polyuria (>30% of 24 H urine production)
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Advanced investigations
• Urodynamic studies (UDS)
o Conventional UDS
o Videocystourethrography (VCU)
o Ambulatory Urodynamic Monitoring (AUM)
• Surface electromyography (EMG)
• Urethral Function tests
• Imaging studies Ultrasound scan
Contrast studies
MRI
• Cystourethroscopy
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Urodynamics Studies (UDS)
Why?
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Urodynamics Studies (UDS)
• Free flow study
• Filling Cystometry
• Voiding cystometry
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Uroflowmetry
• Simple
• Non-invasive
• A Record of voided volume and flow rate
The definition of “Normal study”
o Peak flow rate >15ml/sec
o Voided volume >150ml
o PVRV <100 mls
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Free flow study
Normal Straining
Detrusor under-activity
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Filling Cystometry • Measurement of the detrusor pressure / volume
relationship
• Assess: Bladder sensations, compliance, capacity
• Filling medium: saline, contrast at room temperature
• Filling rate: ? (Weight/4) / min
• Standing positions
• Short, flexible, small (8F) catheters
• Sealed system, no leak, no air bubbles
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Urodynamics
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Urodynamics
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Detrusor overactivity (DO)
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Detrusor over-activity incontinence
(DOI)
Cough
DO
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Voiding cystometry (Pressure flow studies)
The relationship between detrusor pressure and flow rate
• Obstruction High detrusor pressure (>50 cmH20)
Poor flow (<15 mls/sec)
• Under-active detrusor function Low detrusor pressure (<20 cmH20)
Poor flow (<15 mls/sec)
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Urodynamic diagnoses • Detrusor overactivity (DO)
A urodynamic observation characterised by involuntary
detrusor contractions during the filling phase which may
be spontaneous or provoked
• Detrusor overactivity incontinence (DOI)
DO associated with urine leakage
• Urodynamic stress incontinence (USI)
Involuntary leakage of urine during increased abdominal
pressure, in the absence of a detrusor contraction
• Mixed urodynamic incontinence
DO and /or DOI + USI
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Vediocystourethrography (VCU)
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VCU: Advantages, Disadvantages
Advantages:
Simultaneous visualisation of the lower urinary tract
• Trabiculation, Diverticulae, Filling defects
• VU Reflux VCU
• Position of bladder neck in relation to pubic symphysis
• Bladder neck closure during rest and stress
• Fistulae (Vesico-vaginal / uterine, urethro-vaginal )
• Vesico-ureteric reflux
Disadvantages:
• X-ray exposure
• Expensive
• Allergic reaction to contrast media
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Diverticulae
Trabeculation Ureteric reflux
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Ambulatory Urodynamics Monitoring
(AUM)
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Ambulatory urodynamic monitoring
(AUM)
Indications • Failure to reproduce LUTS on UDS
• No response to anti-muscarenics (Question the Dx)
• Failed repeated incontinence operations
• Neurogenic dysfunction
AUM • More accurate assessment of LUTS
• Conventional UDS more sensitive in the diagnosis of USI
• AUM more sensitive in diagnosing DO
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Urethral Pressure profilometry
(UPP)
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Urethral Functions
• Filling Urethro-cystometry
• Voiding Urethro-cystometry
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Urethral Function Tests
Indications
• Voiding difficulties
• Failed prior continence surgery
• Prognosis following continence surgery
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Surface Electromyography (EMG)
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Surface Electromyography (EMG)
• EMG of the urethra, anal sphincters or the pelvic floor
• Established method for LUTS evaluation
The normal EMG pattern
• Progressively increasing EMG activity during filling
(guarding reflex),
and
• Timely relaxation of the pelvic floor during voiding
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Normal EMG
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Imaging studies
• Ultrasound scan
• Contrast studies
• Magnetic resonance imaging (MRI)
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Ultrasound in urogynaecology • Perineal . Introital . Trans-vaginal .Trans-abdominal
Uses
• Bladder neck descent/mobility/opening
• Post-void residuals
• Pelvic pathology (ovarian , uterine)
• Bladder abnormalities (tumour, foreign body)
• Urethral abnormality (diverticulum)
• Urethral sphincter, levator ani anatomy
• Endoanal sonography
• Bladder wall thickness
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BWT in female urology
• Applications for BWT in Urogynaecology
o Voiding dysfunction
o OAB symptoms
• Increased BWT is associated with DO
5 mm cut-off for BWT in diagnosing DO
Sensitivity 40% - 84%
Specificity 78% - 89%
• BWT and the urodynamic diagnoses:
Statistically significant differences in the mean BWT in
women with DO, MUI and USI (DO>MUI>USI)
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Contrast studies
• Videocystourethrography (VCU)
• Intravenous urography (IVU)
• Micturating cystourethrogram (MCU)
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Intravenous urography (IVU)
Provides anatomical outline of the urinary tract including a
nephrogram, calyces, renal pelvis, ureter, bladder
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Micturating cystogram (MCU)
Principal uses, detection of:
• Vesico-ureteric reflux
• Fistulae
• Diverticulae
Trabeculation VU Reflux
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Cystourethroscopy
• Rigid or flexible
• Study anatomy
• Visualisation:
o Calculi
o Tumours
o Diverticulae
• Biopsy of urothelium
o Inflammation
o Cancer
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