URODYNAMICS

LINA, PANDU, MARTHIN, BOBBY, SELLA

URODYNAMICS
The investigation of the function of the lower urinary tract
- the bladder and urethra - using physical measurements
such as urine pressure and flow rate as well as clinical
assessment
AIMS OF URODYNAMICS
1. To reproduce the patients symptomatic complaints
2. To provide a pathophysiological explanation for the patients problems

Urodynamics must reproduce patients symptoms to be of any value



LOWER URINARY TRACT SYMPTOMS
STORAGE VOIDING POST-MICTURITION
Urgency Hesitancy Feeling of incomplete
emptying
Increased Day time
frequency
Intermittency Post-micturition dribble
Nocturia Slow Stream
Urinary incontinence Splitting or Spraying
Altered bladder
sensation
Straining
Terminal dribbling
MECHANISM OF URINE STORAGE
As the bladder fills,
sensory receptors in the
bladder wall trigger the
micturition reflex
Inhibited during filling
resulting in contraction
of the external sphincter
and inhibition of
detrusor contraction,
maintaining continence.
MECHANISM OF VOIDING
Afferent pelvic nerve discharges
ascend in spinal cord, synapse in
pontine micturition centre
Descending efferent pathways cause:
relaxation of sphincter (inhibisi n.
Pudendal S2-S4)
bladder neck to open (inhibisi
n.sympathetic, hypogastric
pleksus T6-T10)
detrusor contraction
(parasympathetic firing; plexus
S2-S4)
FILLING
BLADDER
Low pressure,
compliant reservoir

URETHRA
Closure pressure
must exceed bladder
pressure
Reflex closure
P
P
VOIDING
BLADDER
Coordinated contraction
causes rise in pressure
Complete emptying

URETHRA
Relaxation
P
P
NORMAL FILLING & VOIDING
P
r
e
s
s
u
r
e

(
i
n

b
l
a
d
d
e
r
)

Volume
URODYNAMICS SPECTRUM
OF TESTS
Simple urodynamics
Freq volume charts
Pad testing
Uroflowmetry
Cystometry
Videocystometrography
Ambulatory urodynamics

Complex urodynamics
Urethral pressure measurement
Neurophysiological investigations
Upper tract urodynamics (e.g. the
Whitaker Test)
Pasien dimana terapi potensial dapat merugikan sehingga urolog harus memastikan bahwa
diagnosa yang ditegakkan sudah benar

Pasien dengan inkontinensia rekuren dan direncanakan akan dilakukan operasi

Pasien dengan inkontinensia campuran yang membingungkan antara simptom stres dan
urgensi dan yang berhubungan dengan masalah voiding

Pasien dengan kelainan neurologis dan yang membingungkan antara gejala dan penemuan
klinis.

Pasien dengan LUTS sugestif obstruksi bladder outlet

Pasien dengan LUTS persisten walaupun terapi yang seharusnya sudah diberikan

Indikasi dan Seleksi Pasien untuk Dilakukan Urodinamik
Pasien dengan LUTS yang memiliki gejala obstruktif dan instabilitas yang signifikan
Pasien dengan LUTS obstruktif dan penyakit neurologis
Orang muda dengan LUTS
Semua pasien dengan cacat neurologis yang memiliki disfungsi buli neurogenik
Anak-anak dengan urgensi pada siang hari dan inkontinensia tipe urgensi
Anak-anak dengan enuresis diurnal yang persisten
Anak-anak dengan dysraphism spinal (Kelainan-kelainan saraf yang menyebabkan kandung
kemih rusak)
INVESTIGATION SYMPTOMS POSSIBLE DIAGNOSIS
Uroflow Frequency, nocturia, poor flow Bladder outlet obstruction
Pressure flow Frequency, nocturia, poor flow Bladder outlet obstruction
Cystometry Frequency, urgency Detrusor instability
Urethral closure
pressure
Incontinence Genuine stress incontinence
Ambulatory
urodynamics
Frequency, urgency pointing to
unstable bladder but not shown
on staticurodynamics
Detrusor instability, Genuine
stress incontinence
FREQUENCY VOLUME CHARTS
Patient is instructed to
hold-on to maximum
capacity before each
voiding over 48-72
hours and measure
the volume and time
of each void on a
chart
PAD TESTING
The subjective assessment of incontinence is difficult to interpret and may
not indicate reliably the degree of abnormality.
Problems with test:
Drying out
Perspiration & vaginal discharge
Compliance
Weighing scale accuracy
UROFLOWMETRY
The simplest assessment of voiding dysfunction measurement of
urinary flow rate
Often possible to confirm the presence of bladder outflow obstruction
Device that measures and indicates the volume of fluid passed per unit
time (ml/s)
Often coupled with post-void bladder scan
PERSIAPAN PASIEN
Pengamat seminim mungkin (privasi), bersih, tenang
Penempatan peralatan yang teratur pasien dapat
mudah melakukan miksi
Pasien dianjurkan tidak membuang air sebelum
pemeriksaan, paling sedikit 2 jam sebelum.
Pasien minum yang banyak
Pemakaian obat-obatan yang mempengaruhi hasil
STOP
Pasien sebaiknya memiliki catatan urin output per hari
PRACTICAL TIPS
Consider the rate and the pattern
Voided volumes <150-200 ml unreliable results
Patient should be in favourable surroundings & should not be unduly
stressed
Uroflowmetry alone is insufficient to
diagnose bladder outlet obstruction
because it cannot distinguish true
obstruction from poor detrusor
contractility

A, Schematic of a normal flow curve. Frequently measured variables are noted. B,
Uroflow study in a 60-year-old man. Peak flow rate is 16 mL/sec. Total volume voided is
263 mL. Qura, urine flow rate; Qvol, voided volume.
Uroflowmetri dari pasien pria dengan bukti urodinamik detrusor overaktifitas dan tanda-
tanda urgensi. Lihat akselerasi yang cepat dari aliran pada fase inisiasi, karena
pembukaan tiba-tiba dari sfingter eksterna ketika detrusor berada pada fase kontraksi,
hal ini tak dapat dicegah.
UROFLOWMETRY
Qmax = 19ml/s
The shape of the curve is
unimodal (i.e. monotonic
increase, stable period,
monotonic decrease)
Unobstructed Obstructed
Qmax = 7 ml/s
The shape of the curve is
unimodal (i.e. monotonic
increase, stable period,
monotonic decrease)
Consider poorly contracting
bladder
KEY PARAMETERS
Laki laki muda : 15 20 mL/detik; Abnormal < 10 mL/detik
Angka ini berkurang 1-2 mL/detik per 5 tahun bertambahnya umur.
Ada penurunan peak flow seiring dengan waktu dan pada umur 80 tahun
maksimum flow menjadi 5,5 mL/detik.

Wanita: uretra yang sangat pendek, tahanan outlet yang minimal, tidak ada
prostat dan secara umum satu-satunya faktor yang mempengaruhi uroflow pada
wanita adalah kekuatan otot detrusor dan resistensi uretra dan derajat relaksasi
sfingter.

Pada wanita normal, Qmax dapat lebih besar dari 30 mL/detik, kurva berbentuk
sama seperti pada pria, dan flow time lebih pendek.
Flow max pada wanita tidak tergantung umur.

KEY PARAMETERS
Voided vol. > 150 ml

Qmax > 15 ml/s unlikely obstructed
10-15ml/s equivocal
< 10 ml/s possibly obstructed
or weak detrusor
activity

PVRV - incomplete bladder emptying
CYSTOMETRY
Urodynamic investigation of the filling component of
bladder function.
Measures the pressure/volume relationship of the bladder
Measurement of detrusor pressure during controlled
bladder filling and subsequent voiding with measurement
of flow rate
Used to assess detrusor activity, sensation, capacity and
compliance
Cystometry should evaluate five aspects of bladder
function: sensation, capacity, compliance, stability, and
emptying.
BLADDER COMPLIANCE
The intrinsic ability of bladder to change in
volume without significant alteration in
detrusor pressure
Compliance (ml/cmH2O) = change in volume /
change in detrusor pressure
Normal > 30 40
Abnormal < 30 - 40
DETRUSOR PRESSURE
Cannot be measured
It is estimated/calculated by the automatic
subtraction of rectal pressure (an index of IAP)
from the total bladder pressure, thus removing
the influence of artefacts produced by abdominal
straining

Pdet = Pves - Pabd (=rectal pressure)
Multichannel normal-
filling cystometrogram.
At completion of fill, the
detrusor pressure (Pdet)
is 10 cm H
2
O and there
is no detrusor
overactivity.
Multichannel filling
cystometrogram shows
detrusor overactivity with
multiple contractions. Patient
had idiopathic detrusor
overactivity. C Vol, volume
infused; Pabd, abdominal
pressure; Pdet, detrusor
pressure; Pves, intravesical
pressure.
4 SIMPLE QUESTIONS
1. Is the bladder relaxed during filling?
2. Is the urethra contracted during filling?
3. Does the bladder contract adequately
during voiding?
4. Does the urethra open properly during
voiding?
PRINCIPLES
If a change is seen in both Pves and Pabd but
not in Pdet, then it is due to raised IAP

If a pressure change is seen on Pves and Pdet
and not on Pabd, then it is due to a detrusor
contraction

If a change is seen on Pves, Pabd and Pdet,
then there is both a detrusor contraction and
raised IAP
TECHNIQUE FILLING CYSTOMETRY
4 essential measurements:
1. Intravesical pressure (Pves)
2. Rectal pressure [abdominal] (Pabd)
3. Detrusor pressure (Pdet = Pves Pabd)
4. Urine flow rate to detect leaks
Other optional measurements include:
1. Bladder volume
2. Electromyography
3. Urethral pressure
FILLING
Pves is measured via a urethral catheter
Bladder is filled via UC (sterile H
2
0 or 0.9% NaCl)
Filling should be done with patient standing (or sitting,
for females)
Slow-fill 10 ml/min
Medium-fill 10-100 ml/min
Fast-fill > 100 ml/min

The rate of filling chosen depends on whether the
investigator is trying to reproduce normal
physiological events or to provoke involuntary bladder
contractions whenever possible

BLADDER SENSATION
Assessed during filling
First DV normally about 50% bladder capacity

Normal DV : The feeling that leads patient to void at
next convenient moment; about 75% bladder
capacity

Strong DV : Persistent desire to void without fear of
leakage; about 90% bladder capacity)

Urgency persistent desire to void with fear of
leakage

Pain during filling or voiding is abnormal

DV = Desired Voiding

DETRUSOR ACTIVITY
During filling this can be either normal or
increased (overactivity)
Detrusor overactivity exists, when,
during the filling phase, there are
involuntary detrusor contractions

MEASUREMENTS DURING VOIDING
Premicturition pressure - the pressure recorded just
before the initial isovolumetric contraction
Opening time - time between initial rise in detrusor
pressure to the onset of flow
Opening pressure - pressure recorded at the onset of
measured flow
Maximum pressure - max value of measured
pressure
Pressure at max flow - pressure recorded at Qmax
PRESSURE FLOW PLOTS/ PRESSURE FLOW
STUDIES
The only test that can distinguish between BOO and detrusor
hypocontractility and should be done prior to surgery under
certain circumstances :

- Voided vol < 150 mL in repeated uroflowmetry
- Qmax of uroflowmetry > 15 mL
- LUTS in men > 80 years
- Post-void residual urine > 300 mL
- Suspicion of neurogenic bladder dysfunction
- After radical pelvic surgery
- After unsuccessful invasive BPH treatment

The Abrams Griffiths nomogram was devised as the best method
for separating the pressure flow loops
The assessment of prostatic obstruction from urodynamic measurements and from residual urine.
Abrams PH. Griffiths DJ . British Journal of Urology. 51(2):129-34, 1979
A. Normal filling saat miksi, Qura hanya 4 mL/s (obstruksi)
B. Poor detrusor kontraktilitas peak flow 6 mL/s tapi tanpa kontraksi detrusor.
C. Storage and voiding symptoms sugestif of obstruction Pdet 67, Q ura 11 mL/s
EMG,
electromyogram;
Pabd, abdominal
pressure; Pves,
intravesical
pressure; UroPV,
filling volume.
NOMOGRAMS
Mem-plot pressure vs flow
diagnosa akurat disfungsi miksi :
obstruksi, disfungsi detrusor
atau sebab lainnya.

Sex specific

PRESSURE-FLOW LOOPS WITH
ABRAMS & GRIFFITH NOMOGRAM
Low pressure high flow. The normal urethra is
highly distensible and opens at low pressures.
Unobstructed pressure Flow loop. The tip of the
loop is well into the unobstrcuted zone.
High pressure low flow; if the normal detrusor is
obstructed to give low flow rates it will produce
high pressures.
Note that this is displayed on a different scale
because of the high detrusor pressure. The
patient is highly obstructed.
NORMAL / STABLE BLADDER
STABLE BLADDER ABLE TO ACCOMMODATE ABOUT 500 CC OF FLUID WITHOUT SIGNIFICANT RISE IN
DETRUSOR PRESSURE

UNSTABLE BLADDER
DETRUSOR NORMAL DIISI PERLAHAN MENERIMA 300 600 CC TANPA KENAIKAN TEKANAN. APABILA
BULI MELALUI KONTRAKSI FASIK DI SAAT PASIEN MENCOBA MELAKUKAN MIKSI, INI DINAMAKAN
DETRUSOR OVERACTIVITY. NOTE THE LOW BLADDER CAPACITY
DETRUSOR-SPHINCTER-DYSSYNERGIA
Seen only in patients with neurological
disease
Characterised by phasic contractions of
the intrinsic urethral striated muscle
during detrusor contraction
This produces a very high voiding
pressure and an interrupted flow

VIDEOCYSTOMETOGRAPHY
Uses contrast medium instead of saline
Assesses position and mobility of bladder
neck
Diagnoses diverticulae or reflux
Expensive
Involves radiation
Useful in complex cases where equivocal
results from other tests; apparent failure of a
previous surgical procedure
VIDEO-URODYNAMICS
VIDEO-URODYNAMICS
The simultaneous display of bladder and urethral
pressures with fluoroscopic imaging of the lower tract is
videourodynamics.
Videourodynamics are indicated when a diagnosis cannot
be made with certainty without simultaneous evaluation of
the structure and function of the urinary tract because they
give information on anatomic abnormalities.
Pressure-flow studies only obstruction, not the actual
location, videourodynamics is useful to identify the specific
site of the obstruction as being at the bladder neck, the
prostatic urethra, or the distal sphincter mechanism
Videourodynamic study in a man with voiding and storage lower urinary tract symptoms. The filling
cystometrogram (left) shows high-pressure detrusor overactivity. The micturition study (see vertical event
marker) shows evidence of obstruction with detrusor pressure (Pdet) 123 cm H
2
O at Qmax 6 mL/sec. The
fluoroscopic image (right) at this instant shows a narrowed prostatic fossa. Qmax, maximum flow rate.
THE USE OF VIDEO-URODYNAMICS
Evaluation of incontinence
Bladder neck dysfunction
Neurogenic bladder dysfunction
Identification of associated
pathology
2002 ICS TERMINOLOGY
Detrusor instability old
(Idiopathic) detrusor overactivity new
Detrusor overactivity is a urodynamic diagnosis
i.e. urodynamically demonstrable involuntary
bladder contractions
OAB is a clinical (empirical) diagnosis
Abrams et al. Neurourol Urodynam 2002; 21:167-78
THE END
THANK YOU