Urodynamics

Urodynamics
Introduction

Functional Classification of Voiding Dysfunction

Simple Tests

The Urodynamics Test

Videourodynamics

Urodynamic Risk Factors

Urodynamics
Introduction
The lower urinary tract has two essential
functions:
the storage of urine at low pressure
and the voluntary evacuation of urine

Low pressures are essential to protect

kidneys and assure continence while
voluntary evacuation allows for the
elimination of urine in socially acceptable
situations without fear of leakage or over
distension
Urodynamics

Introduction
It is clear that a number of diseases affect the
lower urinary tract and disrupt the storage and/or
evacuation of urine

This can lead to bothersome symptoms (eg,

urinary incontinence or pain from failure to
empty) or in some cases potentially harmful
sequela

In
many cases, a precise assessment of storage
and emptying is necessary to optimally treat
patients
 Urodynamics

Introduction
Urodynamics (UDS) is the dynamic
study of the transport, storage and
evacuation of urine

It is comprised of a number of tests

which individually or collectively can
be used to gain information about
urine storage and evacuation
Urodynamics

Introduction
UDS is most useful when
history, physical exam and simple tests
are not sufficient to make an accurate
diagnosis and/or institute treatment

Insome cases this may be to obtain

an accurate diagnosis for what
condition is causing symptoms
eg, lower urinary tract symptoms or
incontinence
Urodynamics

Introduction
In others it may be to determine the
impact of a disease that can cause
serious and irreversible damage to the
upper and lower urinary tract
eg, neurological diseases like spinal cord
injury, multiple sclerosis or radiation cystitis

Sometimes profound abnormalities can

be found in the relative absence of
symptoms
Urodynamics

Introduction
In order to use UDS in a practical and
effective way it is important that the
clinician has the proper expertise to know
when and why to perform a UDS study

Despite many technical advances in the

recording, processing and printing of UDS
studies, careful attention to technical
details to assure accurate collection of data
remains the cornerstone of a good study
Urodynamics

Introduction
Since not all patients undergo UDS for the
same reasons, the clinician should customize
UDS to the patients symptoms and condition

That means deciding on the questions to be

answered before starting each study and
designing that study to obtain the answers

It is important to remember that UDS is

performed in an unnatural setting and
therefore does always duplicate real life
Urodynamics

Introduction
A study that does not duplicate
complaints or symptoms when an
abnormality is recorded is not
necessarily diagnostic

In addition, failure to record an

abnormality does not always rule out its
existence (eg, failure to demonstrate
detrusor overactivity in a patient with
urge incontinence)
Urodynamics

Functional Classification of Voiding

Dysfunction
Functionally abnormalities of the
lower urinary tract can be divided
into:
Storage dysfunction (failure to properly
store urine)
Emptying dysfunction (failure to empty
the bladder normally)
Combined dysfunction (failure to store
and empty)
Urodynamics

Functional Classification of Voiding Dysfunction

Anatomically storage and emptying
abnormalities can be caused by:
Bladder dysfunction
Overactive (causing failure to store)
Underactive (causing failure to empty)
Bladder outlet dysfunction
Overactive (causing failure to empty)
Underactive (causing failure to store)
Combined bladder and bladder outlet
dysfunction
The urodynamic evaluation should help to determine if
there is bladder or bladder outlet dysfunction (or both) and
whether there is a storage and/or emptying problem
Urodynamics

Simple Tests
Post-void Residual (PVR)
Excellent assessment of bladder emptying
It can be performed by ultrasound (bladder scan)
or catheterization
Elevation of PVR indicates a problem with
emptying, but does not tell why.
Uroflowmetry
This is also an assessment of bladder emptying.
Normal uroflow is a bell-shaped curve
When the flow rate is reduced or the pattern is
altered, this could indicate bladder (underactive) or
bladder outlet (obstruction) dysfunction.
Urodynamics
Uroflowmetry
Urodynamics

The Urodynamic Test

Urodynamics: Filling and Storage
The cystometrogram (CMG) can
measure filling pressure, sensation,
involuntary contractions, compliance,
and capacity

Sensation is the part of cystometry

that is subjective and requires an alert
and attentive patient and clinician
Urodynamics
The Urodynamic Test
Urodynamics: Filling and Storage

There are several subjective parameters that can be

recorded during filling that are recognized by the
International Continence Society (ICS):
First sensation of bladder filling
First aware of bladder filling
First desire to void
Feeling that would lead patient to pass urine at next convenient
moment, but voiding can be delayed if necessary
Strong desire to void
Persistent desire to void without fear of leakage.
Urgency
Sudden compelling desire to void
 Urodynamics
The Urodynamic Test
Urodynamics: Filling and Storage

Nitti W V. Urodynamics. In: The American Urological Association Educational Review Manual in
Urology. 2nd Edition 2010; Chapter 10: 283-298
Urodynamics
The Urodynamic Test
Urodynamics: Filling and Storage
The simultaneous measurement of
abdominal pressure (Pabd),
usually by a rectal or vaginal
catheter and vesical pressure
(Pves) during urodynamics
provides a means of calculating the
true detrusor pressure (Pdet) by
subtracting abdominal Pabd from Pves
Urodynamics
The Urodynamic Test
Urodynamics: Filling and Storage
The ability to calculate subtracted detrusor
pressure allows one to distinguish between a
true rise in detrusor pressure
either via a contraction or loss of compliance) and
the effect of increased abdominal pressure (eg,
straining, Valsalva)

Thisis important when rises in detrusor

pressure are small or when they are
accompanied by changes in abdominal
pressure
Urodynamics
The Urodynamic Test
Urodynamics: Filling and Storage
Total vesical pressure and intra abdominal pressure
CMG

Multichann
el
Urodynamic
s
Urodynamics
The Urodynamic Test
Abnormalities of Bladder Filling: Detrusor Overactivity and Impaired Compliance
Detrusor overactivity (DO) is a urodynamic
observation characterized by involuntary IDCs
during the filling phase which may be
spontaneous or provoked

According to the ICS, DO may be further

characterized as
neurogenic DO which means it is associated with a
relevant neurological condition (eg, spinal cord injury,
multiple sclerosis)
or idiopathic DO which means that there is no
defined cause (non-neurogenic)
Urodynamics
The Urodynamic Test
Abnormalities of Bladder Filling: Detrusor Overactivity and Impaired
Compliance
The vesicoelastic properties of the bladder,
based on its composition of smooth muscle,
collagen, and elastin, normally produces a
highly compliant structure
as the bladder fills there is little change in pressure

ICS recommends 2 standard points:

the Pdet at start of bladder filling (usually zero)
and the Pdet at cystometric capacity or before the
start of any detrusor contraction that results in
significant leakage
 Urodynamics
The Urodynamic Test
Abnormalities of Bladder Filling: Detrusor Overactivity and
Impaired Compliance
Detrusor overactivity

This UDS tracing depicts DO. Note the 2 IDCs (arrows)

There is a rise in Pves with no associated rise in Pabd and therefore the
subtracted Pdet looks identical to the Pves
 Urodynamics
The Urodynamic Test
Abnormalities of Bladder Filling: Detrusor Overactivity and
Impaired Compliance

Impaired compliance with elevated storage pressures is a

urodynamic risk factor
and usually needs to be treated to prevent renal damage
 Urodynamics
The Urodynamic Test
Abnormalities of Bladder Filling: Detrusor Overactivity and
Impaired Compliance
UDS representation of impaired compliance

Note the rise in Pves (and Pdet) with bladder filling

The Pdet at the end of filling is approximately 45 cmH2O, which is a potentially
dangerous situation
 Urodynamics
The Urodynamic Test
Leak Point Pressures

There are 2 distinct types of leak point pressures that can be

measured in the incontinent patient
The two are independent of each other and measure completely
different things
The first is the abdominal leak point pressure (ALPP)
a measure of sphincter strength or the ability of the sphincter to
resist changes in abdominal pressure
Urodynamics
The Urodynamic Test
Leak Point Pressures
ALPP is the intravesical pressure at
which urine leakage occurs
due to increased abdominal pressure in the
absence of a detrusor contraction
The lower the ALPP, the weaker the
sphincter
There is no normal ALPP, as patients
without stress incontinence will not leak
at any physiologic abdominal pressure
Urodynamics
The Urodynamic Test
Leak Point Pressures
Leak point pressure
 Urodynamics
The Urodynamic Test
Leak Point Pressures
ALPP <60 cm H2O signifies ISD

ALPP between 60-90 cm H2O is

equivocal (there is a component of
ISD)

ALPP >90 cm H2O indicates little or

no ISD
ALPP: Abdominal leak point pressure; ISD: Intrinsic sphincter deficiency
Urodynamics
The Urodynamic Test
Leak Point Pressures
The second type is the detrusor leak
point pressure (DLPP)
a measure of detrusor pressure in patients
with decreased bladder compliance

It is defined as the lowest detrusor

pressure at which urine leakage occurs
in the absence of either a detrusor
contraction or increased abdominal pressure
Urodynamics
The Urodynamic Test
Leak Point Pressures
The DLPP measures the injured
bladder response to increased outlet
resistance

The higher the resistance (eg,

detrusor-external sphincter
dyssynergia), the higher the DLPP,
which is potentially dangerous to the
DLPP: Detrusor leak point pressure
upper tracts
 Urodynamics
The Urodynamic Test
Leak Point Pressures
Pressure in the bladder will continue to increase
as the bladder fills
Leakage at arrow = DLPP = 45 cmH2O

DLPP: Detrusor leak point pressure

 Urodynamics
The Urodynamic Test
Urethral Pressure Profilometry
The urethral pressure profile (UPP) represents the
intraluminal pressure along the length of the urethra in
graphic form
Urethral closure pressure profile (UCP) Is given by the
subtraction of intravesical pressure fromurethral pressure

Maximum urethral pressure (MUP) is the highest

Pressure measured along the UPP

Maximum urethral closure pressure (MUCP) is the maximum

difference between the urethral pressure and the intravesical pressure

Functional profile length is the length of the urethra along which

the urethral pressure exceeds intravesical pressure in women
 Urodynamics
The Urodynamic Test
Urethral Pressure Profilometry
There are no urethral pressure
measurements that:
discriminate urethral incompetence from
other disorders
provide a measure of the severity of the
condition
provide a reliable indicator to surgical
success, and return to normal after
surgical intervention
 Urodynamics
The Urodynamic Test
Stress-induced Detrusor Overactivity
Sometimes detrusor overactivity can be triggered
by a rise in abdominal pressure
The symptom may appear to be stress incontinence
but the condition causing the symptom is an involuntary
contraction
not sphincteric weakness

Occult Stress Incontinence

Stress incontinence is demonstrated in a clinically
continent woman with pelvic prolapse only when
the prolapse is reduced
Urodynamics
The Urodynamic Test
Urodynamics: Emptying The Voiding Phase
Normal voiding accomplished by
activation of micturition reflex,
which involves:
Relaxation of striated urethral
sphincter
Contraction of detrusor muscle
Opening of vesical neck and urethra
Onset of urine flow
 Urodynamics
The Urodynamic Test
Urodynamics: Emptying The Voiding Phase
UDS can evaluate several parameters during
the voiding phase including:

Detrusor contractility

Relaxation of the bladder outlet

Coordination of sphincters
Urodynamics
The Urodynamic Test
Urodynamics: Emptying The Voiding Phase
The Pressure Flow Relation
In males, obstruction has been defined
based on the model of benign prostatic
obstruction (BPO)
The ICS nomogram is the one most
commonly used today
Using this nomogram and the bladder outlet
obstruction index (BOOI) derived from it,
men can be divided into three groups
obstructed, equivocal and unobstructed
 Urodynamics
The Urodynamic Test
Urodynamics: Emptying The Voiding Phase
ICS nomogram

BOOI = PdetQmax 2(Qmax)

 Urodynamics
The Urodynamic Test
Urodynamics: Emptying The Voiding Phase
Obstructionin women cannot be defined by the
ICS nomogramor the BOOI as these will
underestimate female BOO

Women void at much lower pressures than men

and the obstructed female bladder outlet may not
respond as dramatically (or at least with the
same pressures) as in the male

BOOI: Bladder outlet obstruction index

 Urodynamics
The Urodynamic Test
Urodynamics: Emptying The Voiding Phase
Sphincter Coordination
Normal voiding requires external sphincter
relaxation followed by contraction of the detrusor

The external sphincter (and internal sphincter)

should remain relaxed until voiding is complete

The rise in detrusor pressure is preceded by a fall in

urethral pressure and relaxation of the external
sphincter as measured by electromyography (EMG)
Urodynamics
The Urodynamic Test
Urodynamics: Emptying The Voiding Phase
Sphincter Coordination
Urodynamics
The Urodynamic Test
Urodynamics: Emptying The Voiding Phase
Normally EMG activity decreases
before a voluntary bladder
contraction
however it is not abnormal for EMG
activity to increase with an involuntary
contraction as part of a guarding reflex
to inhibit the IDC

EMG: Electromyography
Urodynamics
The Urodynamic Test
Urodynamics: Emptying The Voiding Phase
Not abnormal for EMG activity to increase with
involuntary contraction as part of guarding reflex
inhibiting IDC
 Urodynamics
The Urodynamic Test
Urodynamics: Emptying The Voiding Phase
Detrusor-external sphincter dyssynergia
(DESD) occurs
when there is an involuntary increase external
sphincter associated with DO and also with
voiding
Itis caused by a neurological lesion in the
suprasacral spinal cord
DESD can produce profound changes as the
detrusor involuntarily contracts against a
relatively closed sphincter
 Urodynamics
The Urodynamic Test
Urodynamics: Emptying The Voiding Phase
This will result in high pressures and
can even cause impaired bladder
compliance over time

DESD is considered a urodynamic

risk factor for upper tract
deterioration
 Urodynamics
The Urodynamic Test
Urodynamics: Emptying The Voiding Phase

UDS tracing of a patient with

myelodysplasia and
neurogenic DO and DESD
Note the initial IDC associated
with DESD and incontinence
(measured on the flow
channel)
With refilling, the UDS is again
DO with DESD and then the
patient is told to voluntarily
void and there is persistent
increased EMG activity
As a result there is high
pressure, low flow voiding
(obstruction from the DESD: Detrusor-external sphincter dyssynergia; DO: Detrusor overactivity;
IDC: iIvoluntary Detrusor Contractions
dyssynergic sphincter
 Urodynamics
Videourodynamics
Videourodynamics (VUDS) consists of the
simultaneous measurement of UDS parameters
and imaging of the lower urinary tract
provides the most precise evaluation of voiding function and dysfunction

VUDS is useful when an anatomic picture is

desired:
In cases of known or suspected anatomical abnormality
Failure to demonstrate incontinence by conventional methods
Evaluation of bladder neck (internal sphincter) synergy
Neurological diseases (or other potentially dangerous causes of voiding
dysfunction) where there is associated vesicoureteral reflux
In such cases, reflux volumes and pressures can be measured
 Urodynamics
Videourodynamics
VUDS study of a 45-year-old male with LUTS
including frequency, urgency and decreased force
of stream
 Urodynamics
Videourodynamics
VUDS study of a male with a C1-2 spinal cord injury with
suspected DESD and retention of urine, being considered
for external sphincterotomy
 Urodynamics
Urodynamic Risk Factors
It cannot be emphasized enough that certain UDS
findings are potentially dangerous and usually
require intervention
Impaired compliance
DESD
DISD
High pressure DO present throughout filling
Elevated DLPP (>40 cm H2O)
Poor emptying with high storage pressures
DESD: Detrusor-external sphincter dyssynergia; DO: Detrusor overactivity
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