Dr Kiran Ashok Urogynecologist Urodynamic studies Dr Kiran Ashok Urogynecologist

Irritation Anxiety Parkinsons Infection Urgency Bladder responds similarly to variety of stimulants Irritation Anxiety Parkinsons Infection Symptoms always do not reflect the actual state of bladder Urgency

Urodynamics Observation of the changing function of the lower urinary tract over time

Urodynamic testing

Uroflowmetry Filling cystometry Voiding cystometry or PFS Measure the rate of urine flow Uroflowmetry Fill the bladder & measure Bladder sensation Bladder pressure Bladder compliance Filling cystometry During voiding measure urine flow & bladder pressure simultaneously Voiding cystometry or PFS

Principle of cystometry

Detrusor pressure = Vesical pressure- Abdominal pressure catheter in the bladder measures vesical pressure catheter in the vagina/rectum measures abdominal pressure Detrusor pressure = Vesical pressure- Abdominal pressure

Technique of Cystometry

Quality check

Performing Urodynamic study Clear indication Specific question -Is there detrusor overactivity? -is there an increased bladder sensation? -is the bladder compliance low? -is SUI caused by intrinsic sphincter deficiency?

Urodynamic data should always be interpreted in association with clinical findings

Filling cystometry Filling cystometry is the method by which the pressure/ volume relationship of the bladder is measured during bladder filling. Double lumen catheter in the bladder – one for filling and the other for pressure measurement Single lumen catheter in the vagina or rectum to measure abdominal pressure Leak point pressure measurements are done in filling cystometry

Normal filling cystometry

Increased bladder sensation Increased bladder sensation is defined as an early first sensation of bladder filling or an early strong desire to void that occurs at what is felt to be a low bladder volume and ultimately persists

Filling cystometry – bladder sensations

Detrusor pressure Detrusor pressure during filling should be very low with no involuntary contractions. Detrusor overactivity (DO) is defined as involuntary detrusor contractions during filling that may be spontaneous or provoked

Detrusor Overactivity

Clinically significant detrusor contractions are those which are associated with patient symptoms

Cough Induced DO

Cough induced DO

Provocative maneuvers to elicit DO

Urodynamic stress incontinence  This diagnosis by symptom, sign and urodynamic investigations involves the finding of involuntary leakage during filling cystometry, associated with increased intra-abdominal pressure, in the absence of a detrusor contraction Standerdization of terminology. Int Urogyncol J 2010;21(1):5-26

Urodynamic stress incontinence leak Cough

Urodynamic Stress Incontinence Leak

Leak point pressure The lower the LPP, the weaker is the urethral sphincter

Valsalva Leak point pressure (VLPP) Defined as the intravesical pressure in which urine leakage occurs because of an increased abdominal pressure in the absence of a detrusor contraction Leak point pressure is a measure of the intrinsic sphincter strength of the urethra or its ability to resist leakage with increases in abdominal pressure.

Mixed urinary Incontinence

Bladder Compliance The bladder needs to accommodate the increase in volume without an appreciable rise in bladder pressure. This receptive relaxation property is called bladder compliance Compliance (ml/cm H2O) = change in volume (ΔV) / change in pressure (ΔPdet)

Bladder compliance

Abnormal compliance is related to filling while DO is not Steady raise in detrusor pressure which plateues when filling is stopped and increases when filling is resumed – poor bladder compliance Abnormal compliance is related to filling while DO is not

Abnormal bladder compliance Neurogenic bladdder Prior bladder radiation exposure Multiple bladder surgeries Bladder tuberculosis Recurrent UTI Long standing BOO

Postvoid residual (PVR) urine volume This is an objective assessment of how well a woman empties her bladder. It can be performed by ultrasound or bladder scan or direct catheterization. An elevation of the PVR indicates a problem with emptying

Voiding symptoms Uroflowmetry PVR Voiding cystometry Slow stream Straining to void Feeling of incomplete bladder emptying Urinary retention Uroflowmetry PVR Voiding cystometry

Uroflowmetry

Uroflowmetry Uroflowmetry is a measurement of the rate of urine flow over time It is also an assessment of bladder emptying When the flow rate is reduced or the pattern is altered, this may indicate bladder underactivity or bladder outlet obstruction

Uroflowmetry Uroflowmetry is noninvasive, inexpensive and is best used as a screening test for patients who may have voiding dysfunction.

A normal uroflow is a bell shaped curve

Various Uroflow patterns Detrusor overactivity Straining producing irregular tracing Bladder outlet obstruction Intermittant flow

Interrupted Flow – inappropriate pelvic floor muscle contractions

Measure bladder pressure simultaneously with the flow Low rate of urine flow Underactive detrusor Obstruction How to diagnose? Measure bladder pressure simultaneously with the flow PFS High bladder pressure Low bladder pressure Underactive detrusor Obstruction

Female bladder outlet obstruction Previous Anti-incontinence surgery Anatomic distortion due to cystocele Neurogenic Vaginal mass/cyst/rectocele Compressing urethra Inability to relax pelvic floor – traumatic delivery/ pelvic surgery, Anxiety

Voiding cystometry (pressure flow study)

Low flow + No/ minimal raise in detrusor pressure Voiding cystometry Low flow + High detrusor prssure Obstruction Underactive detrusor Low flow + No/ minimal raise in detrusor pressure

PFS Pressure flow studies are invasive Patient is asked to void with the catheters May not accurately represent normal voiding

Normal pressure flow

Obstructed flow

Obstruction after TVT

Electromyogram (EMG) The study of electronic potentials produced by muscle membranes. Basically to know the action of a muscle EMG is performed with patch electrodes placed on either side of perineum The test is mostly used to assure appropriate coordination between the pelvic floor muscles and lower urinary tract

EMG during normal filling and voiding Muscle action during filling Muscle relaxed during voiding

Comparing normal cystometry with neurogenic bladder

Detrusor –Sphincter dyssynergia

Urodynamic studies - indications

In women with SUI without any other urinary symptoms, UDS are not indicated NICE guidelines 2006

Indications for UDS in SUI Mixed incontinence (coexistent DO) Women who have previously undergone surgery for SUI and developed recurrent incontinence Previous anterior compartment prolapse surgery Women with symptoms suggestive of significant voiding dysfunction.

Pelvic organ prolapse – role of UDS In patients who have lower urinary tract symptoms in conjunction with their prolapse Have evidence of voiding difficulty Outlet obstruction as noted by high PVR

UDS in Overactive bladder conservative or drug therapy fails Indications considering an invasive intervention What to expect Increased bladder sensations Detrusor overactivity

UDS in Mixed Urinary Incontinence Helps to determine the predominant condition – SUI or UUI Detect DO or Increased bladder sensations

Complications of UDS Pain Infection Hematuria Retention

Thank you

To confirm the effects/Adverse effects of intervention or understand the mode of action of a particular type of treatment Voiding dysfunction after TVT

Multichannel urodynamic tests are useful for the assessment of bladder neuropathy and voiding dysfunction.

The use of a VLPP and UPP measurement to assess urethra dysfunction has produced disappointing results. Evolving consensus appears to be that urodynamics is not necessary in all cases of pure SUI and a limited predictive role of lower urinary tract symptoms after anti-incontinence procedures.

Urinary bladder responds similarly to a variety of pathologies Symptoms do not always reflect the actual state of the bladder Eg: woman may feel that her bladder is full, when in fact it may actually be nearly empty

Normal micturition

Normal Urodynamic study

Detrusor overctivity with leak

Fluctuating detrusor pressures

Detrusor overactivity

Detrusor overactivity

Clinician should be actively interacting with the patient Clinician should be actively interacting with the patient. There should be continuous observation and collection of data Pre-procedure Antibiotic prohylaxis indicated in high risk patients

An abdominal leak point pressure is a measure of the intrinsic sphincter strength of the urethra or its ability to resist leakage with increases in abdominal pressure. It is specifically defined as the intravesical pressure in which urine leakage occurs because of an increased abdominal pressure in the absence of a detrusor contraction. Thus it is an objective assessment of the amount of abdominal pressure required to overcome outlet resistance and create leakage.

Uroflowmetry

Pressure flow study Measures pressures in the bladder when a woman is voiding. Detrusor pressure is measured along with simultaneous measurement of urine flow Essential for assesment of voiding dysfunction

Voiding cystometry (PFS) Normal voiding is usually achieved by a voluntarily initiated continuous detrusor contraction that is sustained and can be suppressed.

Bladder outlet obstruction for whatever reason is characterized by increased detrusor pressure and reduced urine flow rate

Filling and voiding cystometry

UPP

Detrusor sphincter dyssynergia

Detrusor acontractility Neurogenic bladder Abnormal compliance DO Filling cystometry BOO Vs Detrusor acontractility Voiding cystometry EMG DSD