Urodynamic Evaluation

of the Lower Urinary Tract

/
Urodynamics (UDS)

Dynamic study of the transport,

storage, and evacuation of urine
Simple UDS
Complex UDS
Electromyography (EMG)
Postvoid Residual (PVR)
Uroflowmetry (UFR)
Uroflowmetry
Maximal Flow Rate

Normal: > 15 mL/sec

Decline with age by 1 to 2 mL/sec per 5
years

Normal: > 20 mL/sec

Independent of age
Uroflowmetry

Flattened pattern

Interrupted pattern
Filling and Storage Phase
Cystometrography (CMG)
Viscoelastic properties of the bladder

Smooth muscle Highly compliant

Collagen structure
Elastin
Abnormalities of CMG
--Detrusor Overactivity
Abnormalities of CMG
--Impaired Compliance
Compliance = volume (ml) / pressure
(cmH2O)
Abnormalities of CMG
--Impaired Compliance
It is difficult to define normal compliance

Absolute pressure is probably more useful

than a compliance number
Abdominal Leak Point Pressure (ALPP)
A measure of urethra sphincter function
Abdominal Leak Point Pressure (ALPP)

Valsalva LPP Cough LPP

VLPP < 60 cm H2O: significant ISD

VLPP 60-90 cm H2O: equivocal
VLPP > 90 cm H2O: little or no ISD
Detrusor Leak Point Pressure (DLPP)
A measure of urethral resistance

DLPP40cmH2O higher risk for upper

tract deterioration (hydronephrosis, reflux)
Urethral Pressure Profilometry (UPP)
A recording of intraluminal pressure
along the length of the urethra
Urethral Pressure Profilometry (UPP)

Functional profile length

Clinical utility is unclear

Voiding and Emptying Phase
Pressure-Flow Study
Low Pdet
High flow rate Normal

High Pdet
Low flow rate Obstruction

Low Pdet
Low flow rate Equivocal
BOO in men:
ICS provisional nomogram

Bladder outlet obstruction index (BOOI)

= PdetQmax 2(Qmax)
Detrusor underactivity in men:
Bladder contractility nomogram

Bladder contractility index (BCI) = PdetQmax + 5(Qmax)

BOO in Women-- A diagnostic dilemma

Cut-points criteria
Qmax < 12 mL/sec + PdetQmax > 20 cmH2O (Axelrod and Blaivas)
Qmax < 15 mL/sec + PdetQmax > 20 cmH2O (Chassagne et
al)
Qmax < 12 mL/sec + PdetQmax > 25 cmH2O (Defreitas et al)

Video-urodynamic criteria
Radiographic obstruction in the presence of a sustained
detrusor contraction (Nitti et al)

Blaivas-Groutz nomogram
Urethral sphincter EMG
Coordination or Discoordination
between the external sphincter and the
bladder
Videourodynamics
-- Localization of obstruction
Videourodynamics
-- Detecting incontinence
Videourodynamics
-- Evaluating VUR
When UDS ?
History, PE, and simple tests are not
sufficient to make an accurate diagnosis
or institute treatment.
Why UDS ?

Symptoms
Sequelae
How UDS ?
Role of UDS in clinical practice
To identify or rule out factors
contributing to LUTD and assess
their relative importance
78 y/o women
Nocturia 3-4 (R/O nocturnal polyuria), slow stream
No systemic disease, no major surgery
 48 y/o man
Weak stream for years, nocturia 3, frequency, UUI
No systemic disease, no major surgery
Sono: prostate 28cc
UFR: 350/8.7/4.4
Role of UDS in clinical practice
To allow a prediction of the possible
consequences of LUTD for the
upper urinary tract
26 y/o women
SCI over T12-L1 level
UUI
Role of UDS in clinical practice

To allow a prediction of the outcome,

including undesirable side effects, of a
contemplated treatment
 76y/o woman
SUI on cough for years and aggravated recently
No weak stream
Role of UDS in clinical practice

To confirm the effects of

intervention or understand the mode
of action of a particular type of treatment
for LUTD, especially a new and or
experimental (preroutine) one
 25y/o woman
Ketamine cystitis with bladder pain and irritative
symptoms
Status post augmentation cystoplasty
 25y/o woman
Ketamine cystitis with bladder pain and irritative
symptoms
Status post augmentation cystoplasty
Role of UDS in clinical practice

To understand the reasons for failure

of previous treatments for urinary
incontinence or for LUTD in general (after
unsatisfactory treatment)
 50y/o woman
Persistent SUI on straining after sling surgery
 References
2012 AUA guideline on urodynamics
11th edition of Campbell-Walsh Urology
Practical Urodynamics