Zahra jabbari khanbeben Imam khomeini hospital

    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

         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

 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.

Dehghan FM,PT,Ph.D

4/24/2020 6

کیژ ول ویزیف ریداقم ندروا تسد هب اب ات تسا رامیب تایاکش و میلاع داجیا یلصا فده .

درک یبایزرا ار یرامیب یاه هناشن یژول ویزیف وتاپ ناوتب و یسررب ا ر راردا هیلخت و هریخذ رد لیخد کیژولوتاپ و کیژولویزیف یاهروتکاف تست نیا دنکیم یبایزرا .

تسین یبایزرا رگید یاهشور زا کیچیه نیزگیاج کیمانیادوروی upp یرتموتسیس یرتمولفوروی : لماش کیمانیادوروی یلصا یاهتست

  

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)

     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 Dehghan FM,PT,Ph.D

4/24/2020 9

• • • •

4 pressures EMG channel Flowmeter Puller

•

Water/gas pump

•

Windows

The 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/secWomen >20cc/sec Mean flow rate (Qave) should be 50% of Qmax Specific to age and gender

  

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

Dehghan FM,PT,Ph.D

4/24/2020 13

I’m relaxed and voiding in privacy Vura Qura

Flow Transducer Urodynamic Equipment

Recording Flow

 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 Dehghan FM,PT,Ph.D

4/24/2020 15

Vura ml 100 Time to 100 ml (Qmax) Maximum Flow Rate Voided Volume Qura ml/s (TQmax) Voided Volume (Qave) Average Flow Rate

Voided Volume / Flow Time

Time to Max. Flow Flow Time Voiding Time Time s

20 10 Flow Rate ml/s Time s Delay Time Max. Flow Rate Time to max. Flow Flow Time Voiding Time Voided Volume Average Flow Rate Residual Volume s ml/s s s s ml ml/s ml 2.5

23.5

3.5

11.3

13.5

120 10.6

90

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 Qmax



10 ml/s 70-90% non-obstructed 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 Qmax



40 ml/s Lower limit Decreased urethral resistance

(Bladder base insufficiency)

Qura Qura Qura

Healthy

Time Qura

Cystocele

Qura Time

Bladder neck rigidity

Time Qura

Benign prosthetic hypertrophy Urethral stricture

Time

Vesico-Sphincter Dyssynergia

Time Time

   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.

Dehghan FM,PT,Ph.D

4/24/2020 23

Cystometry is the recording of the pressure-volume relationship of the bladder during filling.

The method provides information about:    Bladder accommodation by increasing volumes Central nervous control of the detrusor reflex Sensory qualities

Filling

 Water Cystometry, urethra-cystometry  Gas G as-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 sensitivity 20 cmH 2 O/ Div.

P abd P det P ura Q ura P ves Pabd = Abdominal Pressure Pves = Vesical Pressure Pdet = Detrusor Pressure Pura = Urethral Pressure Pclos = Closure Pressure Qura = Urinary Flow EMG = Electromyography EMG

Pdet = Pves – Pabd Pclos = Pves – Pura

   ◦ ◦ ◦ Zero pressure to atmosphere Turn tap open between transducer and patient Initial resting pressures for Pves and Pdet supine – 5-15 cmH 2 0 sitting – 15-40 cmH 2 0 standing – 30-50 cmH 2 0 Initial pressure should be 0-6 cmH 2 0 (80%)

Don't forget to open Pura perfusion!

1000 ml STERILE WATER BAG Pura Pves Pabd Pdet Catheters Pump

Pabd Pves Pura

Pressure Transducers Perfusion Set Recording bladder and urethral pressure reactions during filling with control of abdominal pressure

Filling at 50 ml/ min.

V P 2 2 - V 1 - P 1 EMG Pura UU Pves Pabd Speaking Cough Cough RH Cough P 2 NIDC Pdet P 1 Qura Vinf Leak V 1 2 Time 1 min/Div

Capacity Compliance Competence Sensations Stability

Bladder Capacity ml 150 - 200 I’ve a First Desire.

It’s still a passive desire.

First Desire FD 250 - 300 At home, I would go to toilet.

Here I can wait.

Normal Desire ND 350 - 400 Voluntary Contraction > 500 I’ve got to go but I contract my sphincter to finish what I’m doing.

Strong Desire SD I go to the toilet immediately before I leak.

Urgency UR

      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/cmH 2 0 Ability of bladder wall to distend EFP below 15 cmH females) 2 0 (usually less in Pdet of 40cmH tract 2 0 or > - high risk to upper

 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

 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

   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

Residual Volume Before cystometry < 20 ml ; < 10% Voided Volume Compliance Basic Pressure BP First Desire FD Normal Desire ND Strong Desire Urgency UR Cystometric Capacity SD MCC Main Criteria < 20 cmH 2 O 150 - 300 ml (H 2 O) 250 - 400 ml (H 2 O) 300 - 600 ml < 15 < 20 20-50 - Detrusor Contractions = 0 - Residual Volume = 0 - Compliance = Normal - Cystometric Bladder Capacity = Normal - Normal Desire Progression (SD ml = FD ml + 100)

EMG Pura  Maximum infusion rate 20 ml/ min.

Pves  Detrusor contraction after stimulation (cough)  Low compliance Pabd Pdet Qura Vinf Cough Voiding Phase 0 180 ml

    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)

30°

Bladder filled with 200 ml.

I push with increased force until leaking!

Pabd Leak Qura Delay 0,8 s 96 cm H 2 O Recording Abdominal or Vaginal Pressure, Leak Detection and Flowmeter

Normal persons do not leak at any pressure rise.

Female, leakage at pressure: SLPP >90 cmH 2 O SLPP <60 cmH 2 O SLPP 60-90 Mobile Urethra ISD Equivocal Depend on history, Bladder neck… 80% of patients with SLPP <90 cmH 2 O have ISD Male, diagnosis of post prostatectomy incontinence.

Falsely High LPP High SLPP Large Cystocele absorbing Pabd or obstructing the urethra Simultaneous contraction of the striated sphincter Overactive detrusor SLPP not reliable in the bladder or poor compliance CLPP Difficult to measure correctly as the pressure fluctuations are very fast

Contemporary Urology - April 98 Julian Wan, MD

55-year-old She wets with a small amount of exertion.

Complication of childbirth?

“Re-hitch” her bladder up?

VLPP = 25 cmH 2 O Suggestion?

60 40 20 Infused Volume ml Leakage seen here Pressure at this point = 25 cmH 2 O 200 VLPP = 25 cmH 2 O 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

Contemporary Urology - April 98 Julian Wan, MD

65-year-old 60 She will soon be undergoing surgery for correction of a large cystocele and rectocele.

40 20 She is currently not wet.

VLPP = 30 cmH 2 O after cystocele reduction Infused Volume ml Leakage seen here Pressure at this point = 30 cmH 2 O 200 Would surgery make things worse?

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 the cystocele and rectocele repair.

MCC VB MF MP VE 550 290 24 35 11 12.5

Pves Pabd EMG Qura Recording Bladder, Abdominal Pressure and Electromyography during Voiding phase

EMG Pdet Pves Pabd Qura

Time 30 sec/Div

Low EMG activity during voiding = Synergy Normal Detrusor Pressure Abdominal Pressure for last drops Normal Flow Rate and duration

EMG Pves Pabd Pdet Qura Vura Low EMG activity during voiding High Bladder Pressure No Abdominal Pressure High Detrusor Pressure Prolonged Flow Rate & duration Low Volume Time 1 min/Div

Voiding Phase Max Flow Rate Average Flow Rate Voided Volume Voiding Time Flow Time Time to max Flow Residual Volume Pves at Opening Pves at Max Flow Max Pdet QM VB QM PM 13.5

8.3

290 50 35 12 260 15 37 32 s s s ml/s ml/s ml ml cmH 2 O cmH 2 O cmH 2 O

       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

Pressure

Catheter Pura Puller

Max Closure Pressure Total Urethral Pressure Functional Length Length

Continuous Pulling at 1 mm/sec.

Pura 10 cmH2O PB MP PE

Puller Pump 2 ml/min Damping Tube

Y piece

Pura

Recording Urethral Pressure Pura 54

Main Results

Volume at Profile Max Urethral Pressure Max Closure Pressure Closure Pressure at 30% Closure Pressure at 70% Functional Length Length of Continence Zone Functional Area Continence Area

Stress Profile

Cough Percent of Functional Length Transmission Factor

#

% %

1

10 102 180 72 59 37 41 27 14 795 423

ml cmH 2 O cmH 2 O cmH 2 O cmH 2 O mm mm mm * cmH 2 O mm * cmH 2 O

2

30 70

3

40 50

4

50 30

Length: 138mm EMG Pdet Pves Pabd Qura I I I I I I I I I I I I I I I I Angle: 99° Time 30 sec/Div Pos: 00:20:28