DO NOT MAKE IT DIFFICULT

By:
Sunaryo Hardjowijoto, MD, PhD
Consultant Urologist
2006

Presented at Basic Course For Surgery Trainee

URODYNAMICS
The study of pressure and flow relationships

during the storage and transport of urine within

the urinary tract.
An objective investigation to clarify the
symptoms.
In routine practice mostly focused on the lower
urinary tract.

Urodynamic investigations of the lower

urinary tract:
Investigation of bladder filling and voiding

function
Define bladder storage disorders
Severely voiding dysfunction

LOWER URINARY TRACT:

Bladder
Urethra

Vesicourethral unit:

Store urine adequately

Empty / expulse urine efficiently

The symptoms of vesicourethral unit

dysfunction:
Frequency / urgency (storage symptoms)
Incontinence
Slow stream (voiding / emptying function)
Urinary retention

The urinary bladder:

Main function:
1.
2.

Collection and low pressure storage of urine

Expulsion of urine

Made up of 3 layers:
1.
2.
3.

Outer: adventitial (connective tissue) layer

Middle: smooth muscle with interlacing bundle
Outermost: epithelium of transitional cell

The urethra in male:

Posterior urethra, consists of:
Pars

prostatica
Pars diaphragma

Anterior urethra, consists of:

Pars

bulbosa
Pars pendularis

 The posterior urethra is utmost important for

sphincteric mechanism:
A proximal sphincter/bladder neck mechanism
The distal sphincter mechanism

In females:
Bladder neck is weaker
Urinary continence in women relies upon the
integrity
of
intrinsic
urethral
sphincteric
mechanism

Innervation of vesicourethral units:

The function of vesicourethral units:

1. Storage of urine from the kidneys
2. Expulsion of urine from the bladder

Urine storage:
Intrinsic factor of bladder and urethra:
Tonus

of the muscle and connective tissue:

Urethra: keeps the wall in apposition continence

Bladder walls: exhibit receptive relaxation expands w.o.
increasing pressure

Neural control:
Stretch receptors posterior root of spinal cord lateral
spinothalamic tracts brain (pontine micturition centre)
desire to void

Expulsion of urine:
Bladder filling reach the threshold (bladder capacity)

afferent activity awareness of full bladder

Initiation of voiding:

Under the influence of pontine micturition centre

Relaxation of: urethra
pelvic floor muscles
Funneling of the bladder neck
Proceed with detrusor contraction which is controlled by para
sympathetic pathway
End of voiding closing of proximal urethra

In normal condition:
Bladder capacity: 300 500 ml
Bladder filling pressure: 0 20 cmH2O
Bladder voiding pressure:
40 50 cmH2O (male)
30 40 cmH2O (female)

Urethral closing pressure: 40

cmH2O

Urethral voiding pressure: 0 - 20 cmH2O

Disorders of vesicourethral unit:

1. Disorders of sensation:
Hypersensitive
Hyposensitive
Absent

Terminology of sensation:

First sensation of filling

First desire to void
Strong desire to void
Pain during filling or micturition

Disorders of vesicourethral unit:

2. Disorders of motoric function:
Unstable
Overactive
Underactive
Acontractile

Dysfunction of bladder outflow:

Incompetent leakage w.o. detrusor

contraction
Obstructive: overactivity
mechanical
Dyssynergia

Urodynamic techniques:

Volume voided charts

PAD testing
Flow rate
Intravenous urodynamogram
Cystometry
Videocystometrography
Urethral pressure measurement
Ambulatory urodynamics
Neurological investigation
Whitaker test

Volume voided charts:

=
=

Volume/frequency chart
Voiding diary

A simple noninvasive tool

Its helps to:

Define severity of symptoms

Objectivize the history

Volume voided charts:

=
=

Volume/frequencey chart
Voiding diary

PAD testing:
A simple noninvasive objective method for detecting and quantifiying urine

leakage
The pad is weighed before and after test period (bending and could be extended)
Test schedule:
Start without voiding before
Wear pad
First hour:

Drink 500 ml within a short period

Sit/rest 15 mins
Walk 30 mins, climb stairs
Stand up from sitting 10 X
Hard coughing 10 X
Run 1 min
Bend to pick up something on the floor
Wash hand in running tap water
After 1 hour pad is removed and weighed
Test positive is uncreased 1,4 g/hour

Flowrate (= Flowmetry)
Simplest and most often done investigation to

assest voiding dysfunction

A noninvasive examination
To confirm the presence of B.O obstruction
Result of examination is influenced by:
Detrusor

contractility
Relaxation of sphincter
Patency of the urethra

The Flowmeter
A device that measures and indicates quantity of

fluid passing through the machine per unit time

Types of flowmeters:
Rotating

disk
Electronic dipstick
Gravimetric

The expressed unit: ml/s

The important parameters:

Volume voided
Rate: maximal

average
Pattern:

Continous
Normal
Fast
Prolonged

Intermittent

Flow rate are influenced by:

Volume voided: > 150 ml - < 600 ml
Age
Sex
Surroundings

The Terminology in Flow Rate:

Voided volume
Maximum flow rate (Q max)
Average flow rate
Flow time (T)
T to Q max
Voiding time
Intermittent flow

The graphic of urine flow:

The patterns of flow rate

Cystometry
A method used to measure the relationships between

pressure and volume of the bladder

Measurement of detrusor pressure during filling and
voiding
Could assess:
Bladder compliance
Sensation
Stability
Capacity

Normal cystometrogram

Video cystometrography

The radiologic examination provides

additional information on:
The bladder anatomy
The presence of V.U. reflux
The level of outflow obstruction
The support of the bladder base during coughing