Urodynamic assessment in women with urinary incontinence

Urodynamic assessment in women with urinary

incontinenceZahra jabbari khanbebenImam khomeini hospital

Definition and type of urinary incontinence UI is defined as involuntary leakage of urine that

can affect on health- related quality of life Stress incontinence:involuntary loss of urine with

any increase in intra –abdominal pressure(coughing;laughing;sneezing;…)

Urge incontinence:involuntary loss of urine associated with an urge to void(overactive bladder)

Mixed incontinence:there are both genune stress incontinence and urge incontinence signes

Assessment of urinary incontinence History Dairy chart Urinalysis Physical exam Q tip test Estimation of post void residual Cough stress test Pad test Urodynamic study

Uncertain diagnosis Failure of response to initial therapy Surgical intervention Hematuria Incontinence with coexisting condition Recurrent symptomatic urinary tract infections Incomplete bladder emptying Piror incontinence or radical pelvic surgery or radiation Severe or symptomatic pelvic organ prolapse Neurologic condition Voiding dysfunction or irritative voiding symptoms

Criteria for advance Urodynamic Evaluation (Multichannel ,Urethral Pressure Profile,Videourodynamics &Ambulatory Urodynamics)

Introduction Urodynamics is the general term for the

study of the storage and voiding function/dysfunction of the lower urinary tract.

It is crucial that the UDS reproduce the patient’s presenting symptoms.

04/22/2023 6Dehghan FM,PT,Ph.D

مقادیر اوردن دست به با تا است بیمار شکایات و عالیم ایجاد اصلی هدفلوژیک فیزیو

. کرد ارزیابی را بیماری های نشانه لوژی فیزیو پاتو بتوانتخلیه و ذخیره در دخیل پاتولوژیک و فیزیولوژیک فاکتورهای تست این

میکند ارزیابی و بررسی را ادرار. نیست ارزیابی دیگر روشهای از هیچیک جایگزین یوروداینامیک

سیستومتری : یوروفلومتری شامل یوروداینامیک اصلی uppتستهای

یوروداینامیک مطالعات اهداف

Common Urodynamic Tests Uroflowmetry

◦ Voiding patterns, flow rates (vol/time) Voiding Cystometry

◦ Filling Phase (diagnose incontinence)◦ Voiding Phase – Pressure Flow Study (diagnose

obstruction) Tests performed during Cystometry

◦ Valsalva Leak Point Pressure◦ Urethral Pressure Profiles◦ Concurrent measurement of EMG◦ Uro video (X-ray)

Clinical roles Characterization of detrusor function evaluation of bladder outlet evaluation of voiding function diagnosis and characterization of

neuropathy. As an assessment tool for evaluating

treatment outcomes


Routine Urodynamic Duet Logic

• 4 pressures• EMG channel• Flowmeter• Puller

• Water/gas pump

• Windows

UroflowmetryThe urinary flow reflects the final result of the micturition process:

Detrusor function Bladder neck opening Urethral conductivity

The uroflowmetry measures the flow rate of the external urinary stream by volume per unit time in ml/s.

Measures velocity and duration of micturition Identifies normal vs. abnormal patterns 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 Mean flow rate (Qave) should be 50% of

Qmax Specific to age and gender

Uroflowmetry

The patient Should have a normal desire to void Should be left in privacy Should be instructed TO RELAX and NOT TO:

- Strain- Waggle- Compress of the Urethra

Voiding position should be comfortable


Vura

Qura

Recording Flow

Flow Transducer

Urodynamic Equipment

Uroflowmetry Urodynamic EquipmentI’m relaxedand voiding

in privacy

Uroflowmetry(cont.) Recorded variables during uroflowmetry

study:-flow pattern-voided volume-maximum flow rate(Q max)-flow time-average flow rate(Q mean)-time to maximum flow-voiding time-hesitancy


Time s

Quraml/s

Vuraml 100 (Qmax) Maximum Flow Rate

Flow TimeVoiding Time

(TQmax) Time to Max. Flow

Voided Volume

Voided Volume

(Qave) Average Flow RateVoided Volume / Flow Time

Time to 100 ml

Uroflowmetry Parameters

Results Urodyn 1000

Delay Time s 2.5Max. Flow Rate ml/s 23.5Time to max. Flow s 3.5Flow Time s 11.3Voiding Time s 13.5Voided Volume ml 120Average Flow Rate ml/s 10.6Residual Volume ml 90

Flow Rate ml/s

Time s

10

20

Maximum Flow Rate Value (Qmax)

It is the most important single parameter in flowmetry.

Its interpretation requires familiarity with:Flow curve pattern - voided volume - age and sex

Male Qmax 15 ml/s 70-90% non-obstructedQmax 10 ml/s Infravesical obstruction

(90% true values)

The maximum flow rate normally decreases with age - after 40 - with about 2 ml/s per decade.

Female Qmax 20 ml/s Lower limitQmax 40 ml/s Decreased urethral resistance

(Bladder base insufficiency)

Normal Flows

Low Flows

Intermittent Flows

Qura

Time

Benign prosthetic hypertrophy

Qura

Time

Healthy

Qura

Time

Cystocele

Time

Qura

Urethral stricture

Qura

Time

Bladder neck rigidity

Time

Qura

Vesico-Sphincter Dyssynergia

Flow Typical curves & Pathologies

Residual urine volume It integrates the activity of the bladder and

the outlet during emptying. Can be measured directly by bladder

catheterization, or estimated by uss What is considered a normal PVR is

controversial.- in adults a value less than 25ml is

considered normal , and PVR < 100 warrant carefull surveillance and/or treatment.

- A PVR <100 ml in elderly may under certain circumstances be considered acceptable.


CystometryCystometry is the recording of the pressure-volume relationshipof the bladder during filling.

The method provides information about:

Bladder accommodation by increasing volumes

Central nervous control of the

detrusor reflex Sensory qualities

MethodsFilling Water Cystometry, urethra-cystometry

Gas Gas-cystometry

Pressure Measurement Water Water filled catheters + pressure transducers

Micro-tip catheters

Gas Folley catheter

Patient - Emptied Bladder

- Catheters in place and flushed- Pressure responses OK- EMG response OK- Inform patient about "Desire to void"- Patient relaxed

Equipment- Normal infusion rate 50 ml/ min.- Sweep speed 1 min./

Div.- Pressure sensitivity20 cmH2O/ Div.

Test

Pura

Pdet

Pabd

QuraEMG

Pves

Pabd = Abdominal PressurePves = Vesical PressurePdet = Detrusor PressurePura = Urethral PressurePclos = Closure PressureQura = Urinary Flow EMG = Electromyography

Pdet = Pves – PabdPclos = Pves – Pura

Urodynamic Nomenclature

Zero pressure to atmosphere Turn tap open between transducer and

patient Initial resting pressures for Pves and Pdet

◦ supine – 5-15 cmH20◦ sitting – 15-40 cmH20◦ standing – 30-50 cmH20

Initial pressure should be 0-6 cmH20 (80%)

Signal Testing Before Study

Water Urethra-Cystometry

PressureTransducers

Pura

Catheters

Pves

1000 ml

STERILEWATER

BAG

Pump

Pabd

Perfusion Set

Recordingbladder and urethralpressure reactions

during fillingwith control of

abdominal pressure

Don't forgetto open Pura

perfusion!

Pura

Pves

Pdet

Pabd

0 100 200 300 400 500 600 ml

Leak

NIDC

SpeakingCough

RHCough

Cough

UU

20 m

l

FD ND SD UR MCC

EMG

Pura

Pves

Pabd

Pdet

Qura

VinfTime 1 min/Div

Compliance =V2 - V1

P2 - P1

P2

V2

Cystometry + LPP

P1

V1

Filling at 50 ml/ min.

Basi

c Pr

essu

re

Firs

t Des

ire 1

50-2

00 m

l N

orm

al D

esire

250

-300

m

l

Stro

ng D

esir e

35 0

-400

ml

Leak

Poi

nt P

ress

ure

Urg

ency

& M

axim

um

Capa

city

Compliance Compliance

NIDC = Non-Inhibited Detrusor ContractionRH = Rectal HyperactivityUU = Unstable Urethra

Interpretation of Results: “3C’s” and “2S’s”

Capacity

Compliance

Competence

Sensations

Stability

Desire to VoidBladder Capacity

ml

350 - 400

250 - 300

150 - 200 I’ve a First Desire.It’s still a passive desire.

At home, I would go to toilet.Here I can wait.

I’ve got to go but I contract my sphincter to finish what I’m doing.

I go to the toilet immediatelybefore I leak.

VoluntaryContraction

First Desire FD

Normal Desire ND

Strong Desire SD

Urgency UR> 500

The relationship between change in bladder volume and change in detrusor pressure

Divide the change in volume by the change in detrusor pressure ◦ ( ΔVolume / ΔPdet)

It is expressed as ml/cmH20 Ability of bladder wall to distend EFP below 15 cmH20 (usually less in females) Pdet of 40cmH20 or > - high risk to upper

tract

Compliance

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

Normal◦ Awareness of filling and increasing sensation up to a strong

desire to void Increased

◦ An early and persistent desire to void Reduced

◦ Aware of filling-does not feel a definite desire to void Absent

◦ No sensation of bladder filling/desire to void Non-specific

◦ Perceive bladder filling as abd fullness, vegetative symptoms or spasticity

Bladder pain◦ Abnormal feeling

Urgency◦ Sudden compelling desire to void

Sensations

Stability Detrusor function during filling: 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

Normal ValuesResidual Volume < 20 ml ; < 10% Voided VolumeBefore cystometry

Compliance

Basic Pressure BP < 20 cmH2OFirst Desire FD 150 - 300 ml (H2O) < 15Normal Desire ND < 20Strong Desire SD 250 - 400 ml (H2O) 20-50Urgency UR Cystometric Capacity MCC 300 - 600 ml

Main Criteria - Detrusor Contractions = 0- Residual Volume = 0

- Compliance = Normal- Cystometric Bladder Capacity = Normal

- Normal Desire Progression (SD ml = FD ml + 100)

Clinical Case Detrusor Instability

Maximum infusion rate 20 ml/ min.

Detrusor contraction after stimulation (cough) Low compliance

EMG

Pura

Pves

Pabd

Pdet

QuraVinf

0 180 ml

20 m

l

Cough

Voiding Phase

Is particularly useful to determine if ISD exists in the presence of urethral hypermobility

Bladder filled to 150-200ml (1/2 CC) Patient asked to strain slowly Pressure at which leakage occurs in ALPP (in

absence of detrusor contraction)

Leak Point Pressure

Bladder filled with 200 ml.

I push with increased force until leaking!

VLPP Abdominal In Practice

Leak

Pabd

Qura

RecordingAbdominal or

Vaginal Pressure,Leak Detectionand Flowmeter

30°

60 80100 120

60 80100 120

LeakLeak

96 cmH2O

Delay 0,8 s

Valsalva Leak Point Pressure = SUI

LPP Stress Incontinence - Normal Values

Normal persons do not leak at any pressure rise.

Female, leakage at pressure: SLPP >90 cmH2O Mobile Urethra

SLPP <60 cmH2O ISD

SLPP 60-90 Equivocal Depend on history, Bladder neck…

80% of patients with SLPP <90 cmH2O have ISD

Male, diagnosis of post prostatectomy incontinence.

SLPP - VLPP Pitfalls

Falsely High LPP Large Cystocele absorbing Pabd or obstructing the urethra

High SLPP Simultaneous contraction of the striated sphincter

Overactive detrusor SLPP not reliable in the bladderor poor compliance

CLPP Difficult to measure correctly as the pressure fluctuations are very fast

VLPP Clinical Cases Contemporary Urology - April 98 Julian Wan, MD

VLPP = 25 cmH2O is more suggestive of ISD than urethral hypermobility.Bladder neck suspension with needle procedure will be unsuccessful.Treatment options such as pubovaginal sling may be more appropriate.

ISD: Intrinsic Sphincter Deficiency

55-year-old

She wets with a small amount of exertion.Complication of childbirth?“Re-hitch” her bladder up?VLPP = 25 cmH2O

Suggestion?

200Infused Volume ml

Blad

der P

ress

ure

cmH2

O

20

40

60

Pressure at thispoint = 25 cmH2O

Leakage seen here

VLPP Clinical Cases Contemporary Urology - April 98 Julian Wan, MD

This patient should be studied carefully.Cystocele can lead to a falsely high VLPP and can mask incontinence.You could advise that a pubovaginal sling be done along with thecystocele and rectocele repair.

200Infused Volume ml

Blad

der P

ress

ure

cmH2

O

20

40

60

Pressure at thispoint = 30 cmH2O

Leakage seen here 65-year-old

She will soon be undergoingsurgery for correction of a largecystocele and rectocele.She is currently not wet.VLPP = 30 cmH2O after cystocele reduction

Would surgery make things worse?

550

290

12.5

11

35

24

Voiding-Cystometry

RecordingBladder, Abdominal Pressureand Electromyographyduring Voiding phase

Pves

Pabd

EMG

Qura

VEVB MF MPMCC

Abdominal Pressure for last drops

Low EMG activityduring voiding =Synergy

Normal DetrusorPressure

Normal Flow Rateand duration

Voiding-Cystometry

VB VEQM PM

EMG

Pdet

Pves

Pabd

Qura

Time 30 sec/Div

Cou

gh

Obstructed VoidingEMG

Pves

Pabd

Pdet

Qura

Vura Time 1 min/Div

No AbdominalPressure

Low EMG activityduring voiding

High DetrusorPressure

Prolonged Flow Rate & duration

High BladderPressure

Low Volume

Atonic Bladder

Voiding PhaseMax Flow Rate QM 13.5ml/sAverage Flow Rate 8.3 ml/sVoided Volume 290 mlVoiding Time 50 sFlow Time 35 sTime to max Flow 12 sResidual Volume 260 ml

Pves at Opening VB 15

cmH2OPves at Max Flow QM 37 cmH2OMax Pdet PM 32 cmH2O

Results – Cystometry Voiding Phase

Urethral Pressure Profile = the intraluminal pressure along the length of the urethra with the bladder at rest.

Maximum Urethral Pressure = the maximum pressure of the measured profile.

Maximum Urethral Closure Pressure = the difference between the maximum urethral pressure and the intravesical pressure.◦ Pura – Pves = Pclos urethral closure pressure.

Functional Urethral Length = the length of the urethra along which the urethral pressure exceeds the intravesical pressure. Normal length 1.0-4.0

Anatomic Urethral Length = the total length of the urethra 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

UPPs

Pressure

Length

Pura

Catheter

Puller

UPP - Female

Functional Length

Max ClosurePressure

Total Urethra

lPressure

Pura54Pura10 cmH2O

PB PEMP

RecordingUrethral Pressure

Continuous Pulling

at 1 mm/sec.

Pump2 ml/min

Pura

Y piece

Puller

DampingTube

Urethral Pressure Profile

UPP ResultsMain Results

Volume at Profile 180 ml

Max Urethral Pressure 72 cmH2O

Max Closure Pressure 59 cmH2O

Closure Pressure at 30% 37 cmH2O

Closure Pressure at 70% 41 cmH2O

Functional Length 27 mmLength of Continence Zone 14 mm

Functional Area 795 mm * cmH2O

Continence Area 423 mm * cmH2O

Stress ProfileCough # 1 2 3 4

Percent of Functional Length % 10 30 40 50

Transmission Factor % 102 70 50 30

EMG

Pdet

Pves

Pabd

Qura

Time 30 sec/Div

VB VEQM PM

I I I I I I I I I I I I I I I I

Pos: 00:20:28

Angle: 99°

Length: 138mm

Uro-Video

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Urodynamic assessment in women with urinary incontinence

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