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 Urine
flow studies are the simplest of
urodynamic techniques – noninvasive

 Equipment is simple and relatively

 Urineflow - described in terms of flow rate
and flow pattern (continuous or

 Flow rate - volume of fluid expelled via the

urethra per unit time and is expressed
in ml/s
 Maximum flow rate (Qmax) - Maximum measured value
of the flow rate

 Voided volume (VV) - Total volume expelled via the


 Flow time - Time over which measurable flow occurs

 Average flow rate (Qave) - Voided volume divided by

flow time

 Time to maximum flow - Elapsed time from onset of flow

to maximum flow

 Voiding time - total duration of micturition, including the

Intermittent flow - same measurements
are used as for continuous flow curve

 However, flow time must be measured

carefully, as the time intervals between
flow episodes are disregarded
 Weight Transducer Flowmeter
 Rotating Disc Flowmeter
 Capacitance Flowmeter
Weight transducer flowmeter involves
weighing the urine voided

 Calculates the urine flow rate by

differentiation with respect to time
Rotating-disc flow meter

 Spinning disc on which the urine falls

 The disc is kept rotating at the same speed by a

servomotor, in spite of changes in the urine flow rate
(weight of the urine tends to slow the rotation of the disc)

 The differing power needed to keep disc rotation

constant is proportional to the urine flow rate
Normal Flow Patterns
 When considering the normal flow rates
 Age and Sex
 Voided volume
should be taken into account
 In addition to numerical data , shape of
the trace - important
Normal flow

 “Bell” shape

 Maximum flow is reached in the first 30% of any trace

and within 5 seconds from the start of flow

 Flow rate varies according to the volume voided

 The final phase of a normal flow trace shows a rapid fall

from high flow, sharp cutoff at the termination of flow
 Urine flow rate is highly dependent on the volume voided

 Detrusor muscle when stretched achieves an optimal

performance, but if stretched further it becomes

 At more than 400 ml, the efficiency of the detrusor

begins to decrease and Qmax is lower

 Flow rates are highest and most predictable in the

volume range between 200 ml and 400 ml
Qmax Vs Voided Volume
Flow rate nomograms
 Siroky nomogram
 Bristol nomogram
Siroky Nomogram
Abnormal Flow Patterns
 Urine flow results from the interaction
between the detrusor contraction /
abdominal straining and urethral

 urine flow rates have limitations

which must be appreciated
 Information from urine flow traces, without simultaneous
pressure recording must be interpreted with care

Misleading situations
 Patients with normal flow can have bladder outlet
obstruction when a normal Q max is maintained by
abnormally high voiding pressures

 Patients whose low flow rates are due to detrusor

underactivity rather than to bladder outlet obstruction
Bladder Outlet Obstruction (BOO)

 Low Qmax and reduced average flow, with the

average flow greater than half the Qmax

 Qmax- obtained quickly (3–10 secs), but the flow

rate then decreases slowly

 Terminal dribble
 Obstruction may be

 Compressive - Benign Prostatic Obstruction

 Constrictive - Urethral Stricture

 Constrictive obstruction - “plateau”-shaped trace with

little change in flow rate and little difference between
Qmax and Qave

 Compressive obstruction - first third of the flow trace

may appear relatively normal, Qmax will be reduced,
latter part is elongated into a pronounced “tail” of
reducing flow rate
Detrusor Underactivity (DUA)

 Symmetrical trace with a low maximum flow

rate is seen

 Time to reach Qmax is variable , may occur in the

second half of the trace

 Considerable overlap between - obstructed and

underactive detrusor group – proof comes from a
pressure-flow study
Detrusor Overactivity

 Very high maximum flow rates in abnormally short time

(1 s - 3 s)

 Reduction in time to Qmax is achieved because the

detrusor contraction has already opened the bladder
neck widely, hence reducing the urethral resistance.
Interrupted Flow Patterns

 Irregular Trace
Secondary to
 Habitual
 Obstruction
 DO
 Urethral overactivity
 Artefacts

 Caused by men moving their stream in relation to the

central exit from the collecting funnel

 “Peaks” occur when the point of impact of the stream is

moving down the side of the funnel towards the central

 “Valleys” occur when the impact point is moving

away from the exit

 In an effort to deny the onset of age (and reducing urine

flow), some men have the habit of squeezing the tip of
their penis or foreskin during voiding

 This leads to a series of peaks

 When the patient is asked to stop this , the flow trace

usually becomes classically obstructed, and the flow rate
is no longer within the normal range
 Urine flow studies are an excellent screening study in a
wide variety of patients

 But they must be followed by pressure-flow studies -

precise definition of bladder and urethral function

 Uroflow is used to investigate possible bladder

outlet obstruction and can also give a guide to detrusor

 It can be used for patients of all ages and both sexes

 Uroflow is the screening test of choice in men of
all ages with symptoms suggestive of outlet

 Uroflow should be measured before and after

any procedure designed to modify the function
of the outflow tract
 Qmax is below 10 ml/s then the chance of the
patient having BOO is 90%

 If the Qmax is 10 ml/s to 15 ml/s then the

incidence of BOO is 71% or less

 Because 29% of these patients will not have

BOO, patients with a Qmax of 10 ml/s or more
should have PFS before invasive therapy
AUA Guidelines

 Urinary flow rate measurement is optional

 It is useful in the initial diagnostic assessment and during

or after treatment to confirm response

 Despite the noninvasive nature of the test and its clinical

value, it is an optional test before embarking on any
invasive therapy
AUA Guidelines
 Peak urinary flow (Qmax) is the best single measure to
estimate the probability of a patient to be urodynamically

 But a low Qmax does not distinguish between

obstruction and decreased detrusor contractility

 Because of the intra‐individual variability and the volume

dependency of the Qmax, at least
2 flow rates should be obtained, ideally both with a
volume greater than 150 mL voided urine.