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Urodynamics

Daniel Simanjuntak
Samuel Aji
Enrico Saut
Urodynamics

• The investigation of the function of the lower


urinary tract - the bladder and urethra - using
physical measurements such as urine pressure
and flow rate as well as clinical assessment
Aims of urodynamics

1. To reproduce the patient’s symptomatic


complaints
2. To provide a pathophysiological explanation
for the patient’s problems

Urodynamics must reproduce patient’s


symptoms to be of any value
LOWER URINARY TRACT SYMPTOMS
STORAGE VOIDING POST-MICTURITION
Urgency Hesitancy Feeling of incomplete
emptying
Increased Day time Intermittency Post-micturition dribble
frequency
Nocturia Slow Stream
Urinary incontinence Splitting or Spraying
Altered bladder sensation Straining
Terminal dribbling
Mechanism of urine storage
• As the bladder fills,
sensory receptors in the
bladder wall trigger the
micturition reflex
• Inhibited during filling
resulting in contraction of
the external sphincter and
inhibition of detrusor
contraction, maintaining
continence.
Mechanism of voiding
• Afferent pelvic nerve discharges
ascend in spinal cord, synapse in
pontine micturition centre
• Descending efferent pathways
cause:
– relaxation of sphincter (inhibisi
n. Pudendal S2-S4)
– bladder neck to open (inhibisi
n.sympathetic, hypogastric
pleksus T6-T10)
– detrusor contraction
(parasympathetic firing; plexus
S2-S4)
Filling
BLADDER
• Low pressure,
compliant reservoir
P

URETHRA
• Closure pressure must
exceed bladder
P pressure
• Reflex closure
Voiding
BLADDER
• Coordinated contraction
causes rise in pressure
P • Complete emptying

URETHRA
• Relaxation
P
bladder)
Pressure (in
Normal filling & voiding

Volume
Urodynamics – spectrum of tests
Simple urodynamics Complex urodynamics
• Freq – volume charts • Urethral pressure
• Pad testing measurement
• Uroflowmetry • Neurophysiological
• Cystometry investigations
• Videocystometrography • Upper tract
urodynamics (e.g. the
• Ambulatory urodynamics
Whitaker Test)
Indikasi dan Seleksi Pasien untuk Dilakukan Urodinamik

Pasien dimana terapi potensial dapat merugikan sehingga urolog harus memastikan bahwa
diagnosa yang ditegakkan sudah benar
Pasien dengan inkontinensia rekuren dan direncanakan akan dilakukan operasi
Pasien dengan inkontinensia dan campuran yang membingungkan antara simptom stres
dan urgensi dan yang berhubungan dengan masalah voiding
Pasien dengan kelainan neurologis dan yang membingungkan antara gejala dan penemuan
klinis.
Pasien dengan LUTS sugestif obstruksi bladder outlet
Pasien dengan LUTS persisten walaupun terapi yang seharusnya sudah diberikan
Pasien dengan LUTS yang memiliki gejala obstruktif dan instabilitas yang signifikan
Pasien dengan LUTS obstruktif dan penyakit neurologis
Orang muda dengan LUTS
Semua pasien dengan cacat neurologis yang memiliki disfungsi buli neurogenik
Anak-anak dengan urgensi pada siang hari dan inkontinensia tipe urgensi
Anak-anak dengan enuresis diurnal yang persisten
Anak-anak dengan dysraphism spinal (Kelainan-kelainan saraf yang menyebabkan kandung
kemih rusak)
INVESTIGATION SYMPTOMS POSSIBLE DIAGNOSIS

Uroflow Frequency, nocturia, poor flow Bladder outlet obstruction

Pressure flow Frequency, nocturia, poor flow Bladder outlet obstruction

Cystometry Frequency, urgency Detrusor instability

Urethral closure
Incontinence Genuine stress incontinence
pressure

Frequency, urgency pointing to


Ambulatory Detrusor instability, Genuine
unstable bladder but not shown
urodynamics stress incontinence
on staticurodynamics
Frequency – volume charts
• Patient is instructed to
hold-on to maximum
capacity before each
voiding over 48-72
hours and measure the
volume and time of
each void on a chart
Pad testing
• The subjective assessment of incontinence is
difficult to interpret and may not indicate
reliably the degree of abnormality.
• Problems with test:
– Drying out
– Perspiration & vaginal discharge
– Compliance
– Weighing scale accuracy
Uroflowmetry
• The simplest assessment of voiding
dysfunction – measurement of urinary flow
rate
• Often possible to confirm the presence of
bladder outflow obstruction
• Device that measures and indicates the
volume of fluid passed per unit time (ml/s)
• Often coupled with post-void bladder scan
Persiapan Pasien

• Pengamat seminim mungkin (privasi), bersih, tenang


• Penempatan peralatan yang teratur  pasien dapat mudah
melakukan miksi
• Pasien dianjurkan tidak membuang air sebelum pemeriksaan,
paling sedikit 2 jam sebelum.
• Pasien  minum yang banyak
• Pemakaian obat-obatan yang mempengaruhi hasil  STOP
• Pasien sebaiknya memiliki catatan urin output per hari
Practical tips
• Consider the rate and the pattern
• Voided volumes <150-200 ml  unreliable
results
• Patient should be in favourable surroundings
& should not be unduly stressed
• Uroflowmetry alone is insufficient to diagnose
bladder outlet obstruction because it cannot
distinguish true obstruction from poor detrusor
contractility
A, Schematic of a normal flow curve. Frequently measured variables are noted. B,
Uroflow study in a 60-year-old man. Peak flow rate is 16 mL/sec. Total volume voided is
263 mL. Qura, urine flow rate; Qvol, voided volume.
Uroflowmetri dari pasien pria dengan bukti urodinamik detrusor overaktifitas dan tanda-
tanda urgensi. Lihat akselerasi yang cepat dari aliran pada fase inisiasi, karena
pembukaan tiba-tiba dari sfingter eksterna ketika detrusor berada pada fase kontraksi,
hal ini tak dapat dicegah.
Uroflowmetry
Unobstructed Obstructed

• Qmax = 19ml/s • Qmax = 7 ml/s


• The shape of the curve is • The shape of the curve is
unimodal (i.e. monotonic unimodal (i.e. monotonic
increase, stable period, increase, stable period,
monotonic decrease) monotonic decrease)
• Consider poorly contracting
bladder
KEY PARAMETERS

• Laki – laki muda : 15 – 20 mL/detik; Abnormal < 10 mL/detik


• Angka ini berkurang 1-2 mL/detik per 5 tahun bertambahnya umur.
• Ada penurunan peak flow seiring dengan waktu dan pada umur 80 tahun
maksimum flow menjadi 5,5 mL/detik.

• Wanita: uretra yang sangat pendek, tahanan outlet yang minimal, tidak
ada prostat dan secara umum satu-satunya faktor yang mempengaruhi
uroflow pada wanita adalah kekuatan otot detrusor dan resistensi uretra
dan derajat relaksasi sfingter.

• Pada wanita normal, Qmax dapat lebih besar dari 30 mL/detik, kurva
berbentuk sama seperti pada pria, dan flow time lebih pendek.
• Flow max pada wanita tidak tergantung umur.
Key parameters
• Voided vol. > 150 ml

• Qmax> 15 ml/s – unlikely obstructed


10-15ml/s – equivocal
< 10 ml/s – possibly obstructed
or weak detrusor
activity

• PVRV - incomplete bladder emptying


Cystometry
• Urodynamic investigation of the filling component of bladder
function.
• Measures the pressure/volume relationship of the bladder
• Measurement of detrusor pressure during controlled bladder
filling and subsequent voiding with measurement of flow rate
• Used to assess detrusor activity, sensation, capacity and
compliance
• Cystometry should evaluate five aspects of bladder function:
sensation, capacity, compliance, stability, and emptying.
Bladder Compliance
• The intrinsic ability of bladder to change in
volume without significant alteration in
detrusor pressure
• Compliance (ml/cmH2O) = change in volume /
change in detrusor pressure
• Normal > 30 – 40
• Abnormal < 30 - 40
Detrusor pressure
• Cannot be measured
• It is estimated/calculated by the automatic
subtraction of rectal pressure (an index of IAP)
from the total bladder pressure, thus
removing the influence of artefacts produced
by abdominal straining

Pdet = Pves - Pabd (=rectal pressure)


Multichannel
normal-
filling
cystometrog
ram. At
completion
of fill, the
detrusor
pressure
(Pdet) is 10
cm H2O and
there is no
detrusor
overactivity.

Multichannel filling
cystometrogram shows
detrusor overactivity with
multiple contractions. Patient
had idiopathic detrusor
overactivity. C Vol, volume
infused; Pabd, abdominal
pressure; Pdet, detrusor
pressure; Pves, intravesical
pressure.
4 simple questions

1. Is the bladder relaxed during filling?


2. Is the urethra contracted during filling?
3. Does the bladder contract adequately during
voiding?
4. Does the urethra open properly during
voiding?
Principles
• If a change is seen in both Pves and Pabd but not
in Pdet, then it is due to raised IAP
• If a pressure change is seen on Pves and Pdet
and not on Pabd, then it is due to a detrusor
contraction
• If a change is seen on Pves, Pabd and Pdet, then
there is both a detrusor contraction and raised
IAP
Technique – filling cystometry
• 4 essential measurements:
1. Intravesical pressure (Pves)
2. Rectal pressure [≡abdominal] (Pabd)
3. Detrusor pressure (Pdet = Pves – Pabd)
4. Urine flow rate to detect leaks
• Other optional measurements include:
1. Bladder volume
2. Electromyography
3. Urethral pressure
Filling
• Pves is measured via a urethral catheter
• Bladder is filled via UC (sterile H20 or 0.9% NaCl)
• Filling should be done with patient standing (or sitting,
for females)
• Slow-fill 10 ml/min
• Medium-fill 10-100 ml/min
• Fast-fill > 100 ml/min
The rate of filling chosen depends on whether the investigator is trying to reproduce
normal physiological events or to provoke involuntary bladder contractions whenever
possible
Bladder sensation
• Assessed during filling
– First DV normally about 50% bladder capacity
– Normal DVThe feeling that leads patient to void at
next convenient moment; about 75% bladder capacity
– Strong DV Persistent desire to void without fear of leakage;
about 90% bladder capacity)
– Urgency persistent desire to void with fear of leakage
– Pain Pain during filling or voiding is abnormal

DV = Desired Voiding
Detrusor activity
• During filling this can be either normal or
increased (overactivity)
• Detrusor overactivity exists, when, during the
filling phase, there are involuntary detrusor
contractions
Measurements during voiding
• Premicturition pressure - the pressure recorded just
before the initial isovolumetric
contraction
• Opening time - time between initial rise in
detrusor pressure to the onset of flow
• Opening pressure - pressure recorded at the onset
of measured flow
• Maximum pressure - max value of measured
pressure
• Pressure at max flow - pressure recorded at Qmax
Pressure – flow plots/ Pressure Flow Studies
• The only test that can distinguish between BOO and detrusor
hypocontractility and should be done prior to surgery under certain
circumstances :
- Voided vol < 150 mL in repeated uroflowmetry
- Qmax of uroflowmetry > 15 mL
- LUTS in men > 80 years
- Post-void residual urine > 300 mL
- Suspicion of neurogenic bladder dysfunction
- After radical pelvic surgery
- After unsuccessful invasive BPH treatment

• The Abrams Griffiths nomogram was devised as the best method for
separating the pressure flow loops
The assessment of prostatic obstruction from urodynamic measurements and from residual
urine.
Abrams PH. Griffiths DJ . British Journal of Urology. 51(2):129-34, 1979
EMG,
electromyogram;
Pabd, abdominal
pressure; Pves,
intravesical
pressure; UroPV,
filling volume.

A. Normal filling  saat miksi, Qura hanya 4 mL/s (obstruksi)


B. Poor detrusor kontraktilitas  peak flow 6 mL/s tapi tanpa kontraksi detrusor.
C. Storage and voiding symptoms  sugestif of obstruction Pdet 67, Q ura 11 mL/s
Nomograms

• Mem-plot pressure vs flow  diagnosa


akurat disfungsi miksi : obstruksi,
disfungsi detrusor atau sebab lainnya.

• Sex specific
Pressure-flow loops with Abrams & Griffith
nomogram

Low pressure high flow. The normal urethra is Unobstructed pressure Flow loop. The tip of the
highly distensible and opens at low pressures. loop is well into the unobstrcuted zone.
High pressure low flow; if the normal detrusor is Note that this is displayed on a different scale
obstructed to give low flow rates it will produce because of the high detrusor pressure. The
high pressures. patient is highly obstructed.
Normal / stable bladder
Stable bladder able to accommodate about 500 cc of fluid without significant rise in detrusor pressure
Unstable bladder
Detrusor normal diisi perlahan menerima 300 – 600 cc tanpa kenaikan tekanan. Apabila buli melalui kontraksi fasik di saat pasien mencoba
melakukan miksi, ini dinamakan Detrusor overactivity. Note the low bladder capacity
Schafer Method
Schafer's method for determining urethral resistance is based on consideration
of the urethra as a distensible tube with a flow-controlling zone, the proximal
urethra.
The ICS Provisional Nomogram

Provisional International Continence Society nomogram for analysis of voiding


divides patients into three classes according to the bladder outlet obstruction index
(BOOI) (PdetQmax - 2Qmax). The obstructed BOOI is greater than 40, equivocal
findings are 20 to 40, and unobstructed patients have a BOOI of less than 20.
Qmax, maximum flow rate.
Detrusor-sphincter-dyssynergia
• Seen only in patients with neurological disease
• Characterised by phasic contractions of the
intrinsic urethral striated muscle during
detrusor contraction
• This produces a very high voiding pressure and
an interrupted flow
Videocystometography
• Uses contrast medium instead of saline
• Assesses position and mobility of bladder neck
• Diagnoses diverticulae or reflux
• Expensive
• Involves radiation
• Useful in complex cases where equivocal results
from other tests; apparent failure of a previous
surgical procedure
Video-Urodynamics
Video-urodynamics
• The simultaneous display of bladder and urethral pressures
with fluoroscopic imaging of the lower tract is
videourodynamics.
• Videourodynamics are indicated when a diagnosis cannot be
made with certainty without simultaneous evaluation of the
structure and function of the urinary tract because they give
information on anatomic abnormalities.
• Pressure-flow studies  only obstruction, not the actual
location, videourodynamics is useful to identify the specific
site of the obstruction as being at the bladder neck, the
prostatic urethra, or the distal sphincter mechanism
 Videourodynamic study in a man with voiding and storage lower urinary tract symptoms. The filling
cystometrogram (left) shows high-pressure detrusor overactivity. The micturition study (see vertical event
marker) shows evidence of obstruction with detrusor pressure (Pdet) 123 cm H 2O at Qmax 6 mL/sec. The
fluoroscopic image (right) at this instant shows a narrowed prostatic fossa. Qmax, maximum flow rate.
The Use of Video-urodynamics
• Evaluation of incontinence
• Bladder neck dysfunction
• Neurogenic bladder dysfunction
• Identification of associated pathology
2002 ICS Terminology
• Detrusor instability – old
• (Idiopathic) detrusor overactivity – new
• Detrusor overactivity is a urodynamic
diagnosis
– i.e. urodynamically demonstrable involuntary bladder
contractions

• OAB is a clinical (empirical) diagnosis

Abrams et al. Neurourol Urodynam 2002; 21:167-78


Points to think about
1. What is the role of urodynamics in the
evaluation of men with BOO
2. Role of urodynamics in women with urgency
and urge incontinence
3. Role of urodynamics in patients with mixed
UI (urge incontinence) and SI (stress
incontinence).
THE END
THANK YOU