"#$% &'( )%*+$"$ ,-./0!"#$%&'()* ",-#".

RUMAH SAKIT IBU & ANAK YPK MANDIRI

Jl. Gereja Theresia No.22 Jakarta 10350
Telp. (021)3909725, Fax (021)3903806





Name :
Ages :
Date of Birth :
Date of study :

Sex :
Medical Record :
Clinical Diagnosis :
Physician :

Uroflowmetri
Q-max (ml/s)

Volume voided (ml)

Calculated Residual Urine

Filling Phase
First sensation filling (ml)

Second sensation/strong sensation (ml)

Max.rise in Pdet

Compliance normal reduced

Detrusor instability yes no

Number of Detrusor instability


Contraction no

Vol at contraction

Max.rise in Pdet

Incontinence due to cough yes no
Incontinence with detrusor stability yes no
End-filling Pdet (cmH20)

Cystometric capacity (ml)












1 2 3 4 5




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"#$% &'( )%*+$"$ ,-./0!"#$%&'()* ",-#".

RUMAH SAKIT IBU & ANAK YPK MANDIRI
Jl. Gereja Theresia No.22 Jakarta 10350
Telp. (021)3909725, Fax (021)3903806

Voiding Phase
Opening Pdet (cmH20)

Pdet. Max (cmH20) (Not Pdet.iso)

Pdet. At at peak flow (ml/s)

Peak flow/Qmax (ml/s)

After contraction (0=no; 1=yes) yes no
(Pdet (cmH20))

Volume voided

Residual urine (ml)

Calculated initial residual urine (ml)

Uretral Pressure Profile
1. Rest Profile Evaluation
a. Functional Length

b. Total Length

c. P Closure Max (Pclo.max)

2. Stress Profile Evaluation
a. Pclo stress

b. Tramission factor

c. Stress Test


Reproducibility of the patients symptom yes no






























"#$% &'( )%*+$"$ ,-./0!"#$%&'()* ",-#".

RUMAH SAKIT IBU & ANAK YPK MANDIRI
Jl. Gereja Theresia No.22 Jakarta 10350
Telp. (021)3909725, Fax (021)3903806

Conculsion(s) ( !)
! Urodynamic stress incontinence
! Detrusor overactivity incontinence
! Urodynamic mixed incontinence
! Detrusor overactivity
! Others, explain:

Advice(s) ( !)
! Anti-muscarinic
! Pelvic Floor Training
! Behavioral therapy
! Surgery
! Others, explain
Examination objectives ( !)
! Pre-treatment diagnosis
! Post-treatment diagnosis
! Single-visit diagnosis

Jakarta,



(Name&Signature)