Urodynamics in Practice

Urodynamics Interpretation Course
Dr. Arthur Mourtzinos

Urologist Lahey Clinic, Burlington, MA
Instructor Background

MD, Boston University School of Medicine

General Surgery, Mass General Hospital
Urology, Lahey Clinic Medical Center
Fellowship in male and female pelvic reconstructive surgery
and urinary incontinence, UCLA Medical Center
Expertise in treating patients with complex pelvic injuries,
pelvic floor prolapse, urinary incontinence and cancerrelated abnormalities of the pelvic floor and urinary tract
Course Outline

Urge/Stress Incontinence and Overactive Bladder

LUTS and the Central Nervous System
Introduction to Urodynamics
Uroflow
EMG
Interpretation of the Results
Pressure Flow Studies
UPP Studies
Post Procedure
Patient Study Analysis
Urge/Stress Incontinence
& Overactive Bladder
Patient Assessment

Pelvic Examination
History
H&P
Cystoscopy
Urodynamic Testing
Mechanisms of Continence
All 3 must be present for continence
1. Anatomic integrity of urinary tract
2. Appropriate/intact nervous system
3. Sphincter competence (ex: estrogen)
Stress Incontinence: VLPP

Rest & Straining
Urinary Urge Incontinence

Involuntary leakage accompanied by or immediately
preceded by urgency
Detrusor pressure exceeds urethral pressure
Leakage day and night
Storage / Filling
Detrusor relaxation and urethral contraction
Low detrusor pressure and high urethral pressure
Voiding / Emptying
Detrusor contraction and urethral relaxation
High detrusor pressure and low urethral pressure
LUTS and the

Central Nervous System
Neuro-bladder pathways
Bladder always in the
wanna go mode
Introduction to Urodynamics
Urodynamics
A series of diagnostic studies used to evaluate a
patients ability to store and eliminate urine
The goal is to reproduce bladder filling/storage and
voiding/emptying symptoms to identify underlying
causes
Indications for Urodynamics

Mixed urinary incontinence prior to surgery
Iritative voiding symptoms unresponsive to
conservative therapy or with associated co-morbidities
Incontinence post trauma or pelvic surgery
Failed anti-incontinence surgery
Recurrent UTIs
Spinal Cord Injury, history of neurologic disorders
Children with neurologic disorders, nocturnal enuresis,
or recurrent UTIs
Pressure Measurements

Intra-vesical pressure (Pves)

Abdominal pressure (Pabd)
Detrusor pressure (Pdet)
Electromyography (EMG)
Uroflowmetry (Qura)
Urethral Pressure (Pura)
Urethral Closure Pressure (Pclos)
Intravesical Pressure (Pves)

Combination of abdominal and detrusor forces acting upon the
bladder (cmH20).
Intra-abdominal Pressure (Pabd)
The abdominal forces acting upon pelvic and abdominal
contents. Measured using a rectal or vaginal catheter (cmH20).
Detrusor Pressure (Pdet)
The true pressure of the detrusor contraction derived from
subtraction of Pabd from Pves. It is created by forces in the
bladder wall (passive or active) (cmH20).
Uroflowmetry (Qura)
Screening test measuring vol of urine (ml) expelled from the
bladder in unit of time (ml/sec).
Evaluation of striated sphincter during filling and voiding (uV
amplitude).
Urethral Pressure (Pura)
Fluid pressure needed to just open a closed urethra (cmH20).
VCUG
Radiographic visualization of the lower urinary tract during filling
and voiding.
Pressure Relationships
Uroflow
Uroflow

Measured in cc/second
Observe flow pattern
Review voiding diary for volume voided
Minimum voided volume needed (150-200cc)
Max flow rate (Qmax)
Men >12cc/sec
Women >20cc/sec
Ave flow rate (Qave) should be 50% of Qmax

Specific to age and gender
Post Void Residual

PVR 50ml -100ml = low end of abnormal PVR range
Large PVR 100-300ml will increase risk of UTI and
serious complications
PVR>300ml can cause upper tract dilitation and renal
insufficiency
High PVR Causes: BOO, DSD, Bladder
Hypo/Hypercontractility
Uroflow Parameters
Normal Flow
Low Flow
Intermittent Flow
The Electromyogram (EMG)

Detects pelvic floor muscle activity
Recorded during the filling, cystometry and pressure
flow studies
During a voluntary voiding event the striated muscle of
the external urinary sphincter relaxes as the detrusor
muscle contracts
Filling and voiding (EMG)

During filling, a slight increase in the amplitude of the
EMG may be seen (guarding or continence reflex)
with the urge to void
During voiding this activity should become silent as
the bladder contracts for a synergic voiding event
Interpretation of the Results
Interpretation of Results 3Cs and 2Ss

Capacity
Compliance
Competence
Sensations
Stability
Capacity

Amount of fluid the bladder holds

Slow fill (10cc/min)
Medium fill (10-100cc/min)
Fast fill (over 100cc/min)
Adults: 300ml-600ml (diminishes with age)
Children: (age in years + 2) x 30 = cap in ml
Compliance
The relationship between change in bladder volume
and change in detrusor pressure
It is expressed as ml/cmH20
Detrusor pressure 40 cmH20 may lead to upper
urinary tract dysfunction
Bladder Compliance
Bladder Compliance
Detrusor Over Activity
Atonic Bladder
Competence (of the Sphincter)

Ability of the external striated muscle to hold urine and
relax and release urine
Evaluated using Valsalva Leak Point Pressure (VLPP)
and/or Urethral Pressure Measurement
Sensations
Sensations of patient affected by volume, pressures and
psychosocial environment
First sensation of bladder filling: 60-150ml
becomes aware of the bladder filling
First desire to void: up to 200ml

would void next convenient time, but could hold
Strong desire to void: 400-600ml

persistent desire to void without fear of leak
Stability (Detrusor function)

Normal detrusor function - allows bladder filling with
little or no change in pressure. No involuntary phasic
contractions occur despite provocation.
Detrusor Overactivity - a urodynamic observation
characterized by involuntary detrusor contractions
during the filling phase which may be spontaneous or
provoked.
Pressure-flow Studies
Voiding/Emptying
Pressure Flow - measuring detrusor pressure during
urinary flow
Flow rate: >12ml/sec males and >20ml/sec females

Detrusor pressure: <40cmH20 (<20cmH20 females)
Low flow / high pressure = obstruction
Low flow / low pressure = acontractile bladder
EMG-detrusor/sphincter synergy-quiet during voiding

Normal detrusor pressure vs. Abdominal straining
Post Void Residual (PVR)
High Pressure Low Flow
What kind of prs/flow is this?
Diagnosis
Bladder Outlet Obstruction
Obstructive voiding pattern
High detrusor pressure
Low urine flow rate
Whats happening in this study?
Diagnosis
The PVES catheter fell out at peak pressure during the
voiding phase
Answer
Detrusor Overactivity
Answer
Normal Study
Urethral Pressure Profile

Studies (UPP)
UPPs
Pressure Transmission Ratio = the increment in urethral pressure
on stress as a percentage of the simultaneously reported
increment in the vesical pressure. [cough or dynamic UPPs]
Urinary continence depends on the pressure in the urethra
exceeding the pressure in the bladder at all times, even with
increases in abdominal pressure.
60 90 Normal Closure Pressure
20 60 Intrinsic Sphincter Deficiency
Less than 20 Incompetent Urethra
UPP Diagram
Urethral catheter
being withdrawn
Pressure tracing
Urethral Pressure Profile Measurements
Normal UPP
Post Procedure Instructions

Drink six 12 oz. glasses of
water today
Small amount blood
May have
frequency/urgency for
24-48 hours acmi
Call for temp 101.5

Call if unable to void
after 6 hours
Return appointment
+/- Antibiotics
Written instructions
Thank you for your attention !

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Urodynamics Interpretation Course

Dr. Arthur Mourtzinos

MD, Boston University School of Medicine

Urge/Stress Incontinence and Overactive Bladder

Stress Incontinence: VLPP

Urinary Urge Incontinence

LUTS and the

Indications for Urodynamics

Intra-vesical pressure (Pves)

Intravesical Pressure (Pves)

Ave flow rate (Qave) should be 50% of Qmax

Post Void Residual

The Electromyogram (EMG)

Filling and voiding (EMG)

Interpretation of the Results

Interpretation of Results 3Cs and 2Ss

Amount of fluid the bladder holds

Detrusor Over Activity

Competence (of the Sphincter)

First desire to void: up to 200ml

Strong desire to void: 400-600ml

Stability (Detrusor function)

Flow rate: >12ml/sec males and >20ml/sec females

EMG-detrusor/sphincter synergy-quiet during voiding

High Pressure Low Flow

What kind of prs/flow is this?

Whats happening in this study?

Whats happening in this study?

Whats happening in this study?

Urethral Pressure Profile

Urethral Pressure Profile Measurements

Post Procedure Instructions

Call for temp 101.5

Thank you for your attention !

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