1. Understanding Urodynamics Kim Duggan, RNC

2. Understanding Urodynamics Urodynamics is a study that assess how the bladder and urethra are performing their jobs of storing and releasing urine Urodynamics testing assesses how well the bladder and sphincter muscles work to explain symptoms Urodynamic testing tells the physician if the patient has a Functional Problem or a Structural Problem

3. Patient Complaints Incontinence Frequent Urination Sudden, Strong urges to urinate Problems starting a urine stream Painful urination Problems emptying your bladder completely Recurrent urinary tract infections Pelvic Pain

4. Contributing Factors to Incontinence We get older We loose our hormones We gain weight We carry children We give birth Our pelvic floor weakens

5. Psycho-Social Issues with Incontinence Urinary Incontinence Effects Quality of Life By: Fear of having urine odor Unable to Exercise Fear of Leaking in Public Life revolves around Looking for Restrooms Effects Traveling and Social Life Feelings of being unclean or dirty Effects Intimacy Expensive Undergarment Padding “I’m getting old” or “I’m too young for this to be happening”

6. Types of Incontinence 1. Urge Incontinence: The sudden, intense urge to urinate, followed by a loss of urine. Patients feel like they never get to the bathroom fast enough. These patients are up several times a night with the strong urge to urinate. 2. Stress Incontinence: The unintentional release or leakage of urine during sudden movements such as coughing, sneezing, laughing or exercising.

7. Types of Incontinence 3.Mixed Incontinence: Occurs when women have symptoms of both stress and urge Incontinence. 4.Overflow Incontinence: Occurs when the bladder doesn’t completely empty. It may be caused by dysfunctional nerves or a blockage in the urethra that prevents the flow of urine.

8. URGE INCONTINENCE A sudden involuntary contraction of the muscular wall of the bladder causing urinary urgency, an immediate unstoppable urge to urinate.

9. A Functional Problem Also known as overactive bladder or OAB or OAD Treatment option: Anticholinergics to block the nerve signals related to bladder muscle contractions.

10. Structural Problems Stress urinary incontinence - accidental leaks when you cough, laugh or sneeze - is the most common form of urinary incontinence in women. SUI happens when your sphincter, which acts like a valve to the bladder, can’t stay closed when there’s pressure in your abdomen.

11. SUI is a Structural Problem

12. Steps to Diagnosis Talk with your patients Gather symptoms Understand the emotional component Order a Urodynamic Study A urodynamic study takes the guess work out of diagnosing. It will absolutely define the problem

13. Asking The Right Questions “Do you leak with you cough, laugh, or sneeze?” “Do you ever get the feelings of gotta go, gotta go, gotta go!?!” “Do you not always make it when you are racing for the bathroom?” “How many times do you get up during the night?” “Do you feel a bulge?” “Do you have to shift your upper body to urinate?”

14. The Urodynamic Test

15. The Uroflowmetry A uroflowmeter automatically measures the amount of urine and the flow rate—that is, how fast the urine comes out. Then a Measurement of Postvoid Residual is obtained (PVR)

16. Cystometry

17. Abdominal Pressure Monitoring Another catheter will be placed in the rectum to record pressure there as well. The bladder will be filled slowly with warm water. During this time you will be asked how your bladder feels, noting sensation. The volume of water and the bladder pressure will be recorded, noting capacity and compliance. You will be asked to cough or strain during this procedure. Involuntary bladder contractions can be identified.

18. Electromyography Electroymyography measures external sphincter activity We obtain this measurement by placing EMG leads on the anal sphincter The anal sphincter mimics the external sphincter This allows us to see is that the external sphincter is working in synergy with the detrusor muscle.

19. Valsalva Leak Point Pressure VLPP Measures the lowest abdominal pressure required during a stress activity (such as coughing) that would cause the urethra to open and, therefore, leak. This is where we are checking for urethral competency

20. Pressure Flow Study This is the last step with a urodynamic study. It determines the amounts of detrusor pressure required for the patient to void A detrusor pressure less than 30 is normal for a female

21. What does a urodynamic test tell us Sensation Capacity Compliance Detrusor Activity

22. Capacity The amount of fluid that the patient can comfortably hold

23. Compliance The ability of the bladder to expand and accommodate urine at a low pressure There should be no more than one centimeter of detrusor pressure for every 30 mls of fluid infused Therefore, 300 mls infused volume, the detrusor pressure should be 10 cm or less.

24. Sensation Evaluation of the following four sensation: First Desire: First sensation of filling Normal Desire: First urge to go to bathroom Strong Desire: Stronger urge to go, but not yet imamate Urge: Cannot wait any longer for fear of accidents

25. Detrusor Activity Normal- No contractions are seen during filling phase OAD- One or more contractions during filling phase, regardless of amplitude

26. Detrusor Activity Hyperreflexia –Poorly compliant bladder, where the detrusor pressure “ramps up” during filling phase Hypotonic- Highly compliant bladder, where the detrusor pressure remains very low even at capacity > 500 mls.

27. Detrusor Activity Areflexia- No detrusor activity at all, even with attempt to void. Complete absence of detrusor contraction Autonomic- Usually low volume, high amplitude detrusor contractions with complete bladder emptying

28. Understanding Urodynamics Information that we gather from a Urodynamic Study is used to make a definitive diagnosis and treatment plan