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Urodynamic Study

ABNORMALITIES OF FILLING AND EMPTYING

Filling/Storage Failure
• Absolute or relative failure of the bladder to fill with
and store urine adequately -
– Bladder overactivity (involuntary contraction or
decreased compliance)
– Decreased outlet resistance
– Heightened or altered sensation
Emptying/Voiding Failure
• Absolute or relative failure to empty the bladder
results from
– Decreased bladder contractility
– Increased outlet resistance
Urodynamic Evaluation of Voiding
Dysfunction
• The term urodynamics was first defined by
David M. Davis in 1953 to denote the study of
the storage and emptying phases of the
urinary bladder
• Cystometrograph - D. K. Rose (1927)

• Uroflowmeter - Drake (1948)

• Simultaneous radiographic imaging with


physiologic studies - Hinman and Miller
( 1954 )
• uroflowmetry and cystometry
• pressure-flow studies
• electrophysiologic studies
• urethral pressure studies
• videourodynamic studies
• Aim of urodynamics is to reproduce symptoms
while making precise measurements of the
bladder physiology
Three important principles in urodynamics
(Nitti)
(1) A study that does not duplicate the patient's
symptoms is not diagnostic

(2) Failure to record an abnormality does not rule out


its existence

(3) Not all abnormalities detected are clinically


significant
INDICATIONS
INDICATIONS
PREPARATION OF PATIENTS AND PRECAUTIONS

• Urodynamic studies are invasive


– Not useful in Urinary retention, hematuria, urinary tract infection, and
pain
– Prestudy discussion of the study technique
– Counseling about the risks

• Anticholinergics, α blockers, bladder relaxation medications,


and psychotropic medications - Stopped

• Urine c/s - Negative

• Privacy
• Cystometrogram - Filling component of
bladder function

• Pressure flow study - Measure the relationship


between pressure in the bladder and urine
flow rate during bladder emptying
Cystometrogram
• Filling cystometry: The method by which the pressure and
volume relationship of the bladder is measured during
bladder filling.

• Intravesical pressure: The pressure within the bladder

• Abdominal pressure: The pressure surrounding the bladder (


estimated from rectal, vaginal, or bowel stoma)

• Detrusor pressure: The component of intravesical pressure


created by forces on the bladder wall that are both passive
and active ( pdet = pves - pabd )
• Physiologic filling rate: A filling rate less than
the predicted maximum.
– Predicted maximum is the body weight in kg
divided by 4 ( ml / min)

• Nonphysiologic filling rate: A filling rate


greater than the predicted maximum.
• Information is gained regarding four bladder
characteristics
– Capacity
– Sensation
– Compliance
– Occurrence of involuntary contractions
Compliance
• Bladder compliance is the relationship between change in
volume and change in pressure
( dV/dPdet ) - mL/cm H2O

• During the filling and storage phase of the CMG, increasing


intravesical volumes should occur with little or no change in
intravesical pressure

• Less than 12.5 mL/cm H2O

• Compliance arises from the muscular, collagenous, and elastic


components of the bladder wall
Involuntary contractions
• No involuntary contractions during filling cystometry
• ICS has determined that there is no lower limit for the
amplitude and that any contraction during the study resulting
in the patient's sensation of the need to void is detrusor
overactivity
CMG Tracing
Normally

• Bladder filling occurs with little or no change in pressure

• “Stable” bladder is a reflection of the integrity of the central


nervous system control over bladder function

• There should be no involuntary contractions during filling


cystometry
• Normal bladder capacity is in the range of 300 to 500 mL

• Bladder should have a constant, low pressure that usually


does not reach more than 6 to 10 cm H2O above baseline at
the end of filling (end-filling pressure)

• There should be no involuntary contractions.


Pitfalls - Cystometry
• If bladder filling is too rapid, even a normal detrusor may
appear to have low compliance

– Identification of low compliance should be confirmed by


repeated filling at a much slower fill rate

• If the bladder outlet is incompetent, urine may leak around


the filling catheter and a low bladder compliance may not be
diagnosed because the bladder is never adequately filled
(e.g., spinal dysraphism, severe intrinsic sphincter deficiency
[ISD] )

– Test repeated by using a Foley catheter for bladder filling


which is pulled down to occlude the bladder neck.
Pitfalls - Cystometry
• In patients with reflux, large volumes of the filling
solution may reflux into the dilated upper tracts and
a low-capacity, low-compliance detrusor may be
missed because of this “pop-off” mechanism
Leak Point Pressure
• DLPP – Detrusor Leak Point Pressure
• ALPP – Abdominal Leak Point Pressure
(Valsalva Leak Point Pressure)

- The DLPP is a measure of the urethral resistance during a


detrusor contraction

- The detrusor pressure tends to force the urethral sphincter


open

- whereas abdominal pressure does not open a normally


positioned and closed urethral sphincter
DLPP
• Definition - Lowest detrusor pressure at which urine leakage
occurs in the absence of either a detrusor contraction or
increased abdominal pressure

• The DLPP was first introduced by McGuire and associates for


the evaluation of patients with low bladder compliance
secondary to myelodysplasia
DLPP
• An important concept in urodynamics is the fact that bladder
outlet resistance is the main determinant of detrusor pressure

• If the outlet resistance is high, a higher bladder pressure is


needed to overcome this resistance and cause leakage. This
high pressure can be transmitted to the upper tracts, causing
reflux and hydronephrosis
DLPP
• DLPP greater than 40 cm H2O were at significantly
higher risk for upper tract deterioration

• The test is performed during cystometry. The


urethral meatus is observed for leakage while
bladder pressure is measured. When leakage of urine
is noted, the Pdet at that instant is recorded as the
DLPP
Abdominal Leak Point Pressure
• ALPP is the intravesical pressure at which urine leakage occurs
because of increased abdominal pressure in the absence of a
detrusor contraction

• Leakage can be caused only by an increase in abdominal


pressure when the urethra is abnormal

• Testing for ALPP should be done during cystometry after the


bladder has been filled to at least 150 to 200 mL. The patient
is then asked to do a Valsalva maneuver until he or she leaks .

• The lowest pressure at which incontinence occurs is the VLPP


VLPP

• < 60 cm H2O - Significant ISD


• 60 to 90 cm H2O - Equivocal (combination of
Urethral hypermobility and ISD)
• > 90 cm H2O - Urethral Hypermobility and minimal
ISD
Bethanechol Supersensitivity test
• A neurologically intact bladder should have a pressure
increase of less than 15 cm H2O above the control value,
whereas a “denervated” bladder shows a response greater
than 15 cm H2O

• A positive test suggests an interruption in the afferent or


efferent peripheral, or distal spinal innervation

Sensitivity 76%
Specificity 50%
Ice water test
• Differentiate “upper” from “lower” motor neuron lesions

• Based on the principle that mucosal temperature receptors


can elicit a spinal reflex contraction of the detrusor, a reflex
that is normally inhibited by supraspinal centers

• A positive test occur in UMN lesions, whereas those with LMN


lesions and normal patients will have a negative test
Pressure-Flow Studies
• Pressure-flow studies measure the relationship
between pressure in the bladder and urine flow rate
during bladder emptying

• Pdet Qmax
• Pdet Qmin – Minimum pressure at the end of
micturition when the urethra is in relaxed state
• Qmax
• Differentiate patients with low flow because of
obstruction from those with poor bladder
contractility.

• Identify patients with high-pressure obstruction and


normal flow rates

• when combined with fluoroscopic screening or a


sphincter EMG study, the site of obstruction may be
determined
• There is no consensus regarding a critical value for pressure
and flow that is diagnostic for obstruction

• Normal male generally voids with a Pdet of 40 to 60 cm H2O

• Women void with lower pressures


• PFSs are especially useful in the evaluation of men
with LUTS because approximately one third of older
men with LUTS do not actually have any urodynamic
evidence of obstruction
• Older men with LUTS and any history of neurologic disease
such as cerebrovascular accident, multiple sclerosis, or
Parkinson's disease, which are known to affect detrusor or
sphincter function.

• Younger men with LUTS benefit from PFSs to determine


whether a functional disorder (e.g., bladder neck dysfunction)
is present.

• PFSs are also helpful in men with BPH and Qmax over 10
mL/sec, a group making up 30% to 40% of BPH patients. Of
these, PFSs would suggest that only 12% require surgery for
obstruction
Nomograms
• Abrams-Griffiths Nomogram
• Schafer’s Nomogram
• URA Nomogram
• ICS Nomogram
• Nomograms are obtained by plotting pressure
against flow

• It is sex specific
Abrams-Griffiths Nomogram
• Constructed with three regions by plotting Qmax and
PdetQmax measurements
• Patient may be categorized as obstructed, equivocal,
or unobstructed
• Equivocal group
– Minimal voiding pressure is higher than 40 cm H2O,
obstruction is present
– Slope of the line joining the PdetQmin location and the
PdetQmax*Qmax point is more than 2 cm H2O/mL/sec,
obstruction is diagnosed
slope = (pdetQmax – pdet min)/Qmax
AG number = PdetQmax - 2Qmax
• AG number is an estimate of PdetQmin
– Greater than 40 – Obstruction
– Less than 20 - No obstruction
– 20 to 40 - Equivocal
Schafer’s Nomogram

• Method for determining urethral resistance

• Describes the relationship between pressure and flow during


the period of lowest urethral resistance and thus reflects the
passive anatomic factors responsible for the outlet resistance

• Linear PURR( Passive Urethral Resistance Ratio)

• The linPURR line is constructed by linking the Pmuo, the


relative lowest detrusor pressure at which flow starts or stops,
to the PdetQmax point

• Grade 0 (no obstruction) to 6 (severe obstruction)


ICS Nomogram
• It is very similar to the AG nomogram except that the
boundary between unobstructed and equivocal has
been moved to reduce the size of the equivocal
region

• Bladder outlet obstruction index (BOOI), which is


essentially the AG number, given by the formula
BOOI = PdetQmax - 2(Qmax).
Bladder Contractility Index (BCI)
• PdetQmax + 5Qmax
– Greater than 150 is strong
– Less than 100 is weak
– 100 to 150 is normal contractility
AMBULATORY URODYNAMICS
• Ambulatory urodynamic studies are defined as a
functional test of the lower urinary tract, (especially
of incontinence episodes) using natural filling and
reproducing the subject’s everyday activities
• Ambulatory UDS has its greatest value in patients in
whom conventional UDS is not suitable or is unable
to reproduce symptoms in question.
• Disadvantage ;for many findings in ambulatory
urodynamics, both normal and abnormal standards
have not been established
Video-Urodynamics
• VUDS is the procedure of choice for documenting
bladder neck dysfunction in men and women.
Patients at high risk for complicated voiding
dysfunction such as those with known or suspected
neuropathic voiding dysfunction, unexplained urinary
retention in women, prior radical pelvic surgery,
urinary diversion prerenal or postrenal transplant, or
prior pelvic radiation should be considered for VUDS
Urodynamics in Children
• Neurological disease and Vesicourethral
dysfunction
• Lower urinary tract symptoms / dysfunction
• Non-neurological congenital abnormalities
and Vesicourethral dysfunction.
Children with Neurological Disorders
• The role of urodynamics is to make the crucial
functional distinctions between a high-
pressure bladder (unsafe) and a low-pressure
one (safe), the former being associated with
the worse prognosis
Children Born with Non-Neurological
Defects
Urethral valves

• Boys born with urethral valves have often been diagnosed


prenatally and are treated very early in life. However there
are often long-term sequelae to valves, with poor bladder
compliance and upper tract dilatation.

• These boys need to be followed in a similar fashion to the


meningomyelocele children with early urodynamics if there is
upper tract dilatation.
Normal Children with Vesico-Urethral
Dysfunction
• No physical abnormality

• Enuresis and daytime incontinence or


recurrent urinary infections

• On urodynamic investigation the main


abnormalities found are detrusor overactivity,
dysfunctional voiding and vesico-ureteric
reflux
Enuresis

• Detrusor overactivity, low bladder capacity, reduced


bladder sensation, failure of arousal from sleep and
overproduction of urine at night

• Management involves a presumptive diagnosis


followed by empiric treatment

• UDS – required in small percentage of pts


vesico-ureteric reflux

• If screening studies, flow rates and ultrasound


estimates of residual urine, together with
upper tract ultrasound, are normal then
urodynamics is not indicated.

• If reflux and upper tract dilatation coexists


then urodynamics is indicated
Indications for Urodynamic Investigation
in Children

• If results will affect management.

• Empirical treatment has failed and invasive therapy


is contemplated requiring
confirmation of the presumptive diagnosis.

• Screening tests have been shown to be abnormal


Urodynamics in Women
• One of the principal roles for urodynamics is the
identification of the main cause of incontinence,
detrusor or urethral

• As incontinence occurs with a high prevalence in the


community, it is unrealistic and unnecessary for all
women to have urodynamic studies to confirm a
diagnosis.
Stress Urinary Incontinence
There are several advantages to performing UDS on all
women before invasive surgery:
• Confirmation of incontinence and its cause.
• Definition of detrusor activity during filling.
• Assessment of detrusor voiding function.
• Assessment of degree of sphincter weakness.
• Assessment of pelvic floor function.
• Twelve percent of women with apparently
pure stress incontinence can be shown to
have detrusor overactivity rather than USI as
the cause of their symptoms
Urodynamics in the Neurological Patient

• Neurogenic Detrusor Overactivity

• Functional bladder outlet obstruction


secondary to urethral overactivity
(detrusor-sphincter dyssynergia)
LMN Lesion
• Bladder sensation is lost.
• Detrusor contractility is absent.
• Bladder compliance may be reduced.
• Sphincter function is reduced.
• Voiding is by straining.
UMN Lesion
• Bladder sensation is lost.
• Detrusor overactivity is likely.
• Bladder compliance may be reduced.
• Sphincter function is normal during filling but
may be overactive during voiding. (DSD)
• Voiding is reflex
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