urodynamics in practice
DESCRIPTION
clinical aspects or urodynamicsTRANSCRIPT
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Urodynamics Interpretation Course
Dr. Arthur MourtzinosUrologist Lahey Clinic, Burlington, MA
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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 cancer-
related abnormalities of the pelvic floor and urinary tract
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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
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Urge/Stress Incontinence
& Overactive Bladder
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Patient Assessment
Pelvic Examination
History
H&P
Cystoscopy
Urodynamic Testing
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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)
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Stress Incontinence: VLPPRest & Straining
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Urinary Urge Incontinence
Involuntary leakage accompanied by or immediately
preceded by urgency
Detrusor pressure exceeds urethral pressure
Leakage day and night
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Storage / Filling
Detrusor relaxation and urethral contraction
Low detrusor pressure and high urethral pressure
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Voiding / Emptying
Detrusor contraction and urethral relaxation
High detrusor pressure and low urethral pressure
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LUTS and the
Central Nervous System
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Neuro-bladder pathways
Bladder always in the
wanna go mode
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Introduction to Urodynamics
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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
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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
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Pressure Measurements
Intra-vesical pressure (Pves)
Abdominal pressure (Pabd)
Detrusor pressure (Pdet)
Electromyography (EMG)
Uroflowmetry (Qura)
Urethral Pressure (Pura)
Urethral Closure Pressure (Pclos)
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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).
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Uroflowmetry (Qura)
Screening test measuring vol of urine (ml) expelled from the bladder in unit of time (ml/sec).
Electromyography (EMG)
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.
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Pressure Relationships
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Uroflow
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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
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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
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Uroflow Parameters
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Normal Flow
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Low Flow
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Intermittent Flow
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Electromyography (EMG)
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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
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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
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Interpretation of the Results
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Interpretation of Results 3Cs and 2Ss
Capacity
Compliance
Competence
Sensations
Stability
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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
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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
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Bladder Compliance
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Bladder Compliance
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Detrusor Over Activity
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Atonic Bladder
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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
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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
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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.
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Pressure-flow Studies
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Voiding/Emptying
Pressure Flow - measuring detrusor pressure during urinary flow
Flow rate: >12ml/sec males and >20ml/sec females
Detrusor pressure:
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High Pressure Low Flow
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What kind of prs/flow is this?
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Diagnosis
Bladder Outlet Obstruction
Obstructive voiding pattern
High detrusor pressure
Low urine flow rate
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Whats happening in this study?
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Diagnosis
The PVES catheter fell out at peak pressure during the
voiding phase
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Whats happening in this study?
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Answer
Detrusor Overactivity
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Whats happening in this study?
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Answer
Normal Study
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Urethral Pressure Profile
Studies (UPP)
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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
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UPP Diagram
Urethral catheter being withdrawn
Pressure tracing
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Urethral Pressure Profile Measurements
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Normal UPP
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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
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Thank you for your attention !