Campbell-Walsh Urology, 11th Edition

PART XII

Urine Transport, Storage, and Emptying

73

Urodynamic and Video-Urodynamic Evaluation of the Lower Urinary Tract

Victor W. Nitti; Benjamin M. Brucker

Questions

1. Indications for urodynamic studies (UDS):
2. are supported by high-quality, level 1 evidence for most conditions.
3. are better defined for men than for women.
4. are best defined by the clinician who has clear-cut reasons for performing the study and will use the information obtained to guide treatment.
5. are of little value in assessing a patient with neurogenic lower urinary tract dysfunction.
6. are only useful in women when incontinence is seen clinically.
7. The American Urological Association/Society for Urodynamics and Female Urology Urodynamics Guideline findings and recommendations:
8. are all supported by level 1 or 2 evidence.
9. do not apply to patients with neurogenic lower urinary tract dysfunction.
10. are intended to assist the clinician in the appropriate selection of urodynamic tests, following evaluation and symptom characterization.
11. include recommendations on standardization of urodynamic equipment.
12. do not consider expert opinion.
13. Which of the following tests assesses bladder compliance?
14. Cystometrogram
15. Micturitional urethral pressure profile
16. Postvoid residual volume
17. Voiding pressure flow study
18. Electromyogram
19. Detrusor pressure:
20. can be measured directly via a transurethral catheter.
21. should remain low (near zero) during bladder filling.
22. rises abruptly and does not return to baseline with detrusor overactivity.
23. rises before the external sphincter relaxes in normal voluntary micturition.
24. is obtained by adding the abdominal pressure to the vesicle pressure.
25. Detrusor overactivity (DO):
26. is synonymous with overactive bladder.
27. is necessary to make a diagnosis of urodynamic bladder outlet obstruction.
28. can be seen on UDS of asymptomatic men and women.
29. is commonly associated with renal deterioration.
30. is a diagnosis made based on history alone.
31. The hallmark of bladder outlet obstruction is:
32. incomplete bladder emptying.
33. low pressure–low flow voiding dynamics.
34. high pressure–low flow voiding dynamics.
35. impaired detrusor contractility.
36. elevated postvoid residual.
37. The external urethral sphincter should normally:
38. relax with an involuntary bladder contraction in a neurologically normal person.
39. relax prior to a voluntary detrusor contraction in a neurologically normal person.
40. progressively relax while the bladder fills.
41. always contract when the detrusor contracts.
42. contract during urination in a neurologically normal person.
43. Videourodynamics (VUDS):
44. is the most precise measure of lower urinary tract function and should be used in all cases in which UDS is to be performed.
45. is required to assess obstruction in a man.
46. is the procedure of choice for documenting bladder neck dysfunction in men and women.
47. is impractical to perform in spinal cord–injured patients.
48. is needed to confirm detrusor overactivity.
49. Urethral function tests such as abdominal leak point pressure (ALPP) and maximum urethral closure pressure (MUCP):
50. can precisely define intrinsic sphincter deficiency (ISD).
51. should be done routinely before all surgery for stress incontinence.
52. are the most important part of the UDS assessment of women with stress urinary incontinence.
53. should not be used as a single factor to grade the severity of incontinence.
54. can only be performed during ambulatory urodynamics.
55. Which of the following conditions/factors may result in inaccurate measurement of bladder compliance?
56. Prior radiation to the pelvis
57. Use of fluid-filled urodynamic catheters
58. Presence of vesicoureteral reflux
59. Bladder outlet obstruction
60. History of genitourinary (GU) tuberculosis (TB)
61. According to the Functional Classification System, the symptom of stress incontinence can be classified as:
62. failure to store secondary to an overactive bladder outlet.
63. failure to store secondary to an overactive bladder.
64. failure to store secondary to an underactive bladder outlet.
65. failure to empty secondary to an underactive bladder outlet.
66. failure to empty secondary to an overactive bladder outlet.
67. During multichannel urodynamics, what is the best measure that allows the clinician to look for abdominal straining occurring during micturition?
68. Rectal or vaginal catheter pressure
69. Bladder catheter pressure
70. Uroflow pattern
71. Electromyogram activity and uroflow velocity
72. Postvoid residual
73. For women with stress incontinence, UDS has its most useful role in which of the following scenarios?
74. In women who are considering surgical correction who also have urgency incontinence symptoms or difficulty emptying the bladder
75. In predicting outcomes of surgery for women with pure stress incontinence
76. In predicting the likelihood of voiding dysfunction in women with pure stress incontinence
77. In predicting outcomes of conservative, nonsurgical treatments for women with mixed incontinence
78. Prior to starting conservative, nonsurgical treatments for women with pure incontinence

Answers

1. c. Are best defined by the clinician who has clear-cut reasons for performing the study and will use the information obtained to guide treatment.UDS has been used for decades, yet clear-cut, level 1 evidenced-based “indications” for its use are surprisingly lacking. There are a number of reasons for this. It is difficult to conduct proper randomized controlled trials on UDS for conditions in which lesser levels of evidence and expert opinion strongly suggest clinical utility and in which "empiric treatment" is potentially harmful or even life-threatening (e.g., neurogenic voiding dysfunction). In addition, symptoms can be caused by a number of different conditions, and it is difficult to study pure or homogeneous patient populations. Given the current state of evidence for UDS studies, what is most important is that the clinician has clear-cut reasons for performing the study and that the information obtained will be used to guide treatment of the patient. Despite having established nomograms for bladder outlet obstruction in men, the indications for UDS in men are no more clear-cut than they are in women. UDS probably has its most important role in the diagnosis and management of patients with neuropathic voiding dysfunction. In straightforward cases of pure stress urinary incontinence (SUI) where incontinence is seen clinically, urodynamics may not needed.
2. c. Are intended to assist the clinician in the appropriate selection of urodynamic tests, following evaluation and symptom characterization.The intent of the guideline was to assist clinicians in the appropriate selection of tests rather than to provide absolute indications for UDS. The review of literature produced few articles offering a high level of evidence, and most of the recommendations are based on lower levels of evidence, expert opinion, and clinical principles.
3. a. Cystometrogram (CMG). Compliance is the change in bladder volume/change in bladder pressure.Bladder pressure during filling is assessed by CMG.
4. b. Should remain low (near zero) during bladder filling.Detrusor pressure normally remains low during filling, as the bladder is highly compliant. It cannot be measured directly with a transurethral catheter, but must be obtained via subtraction of abdominal pressure from vesicle pressure. With detrusor overactivity, pressure usually returns to baseline after the involuntary contraction abates.
5. c. Can be seen on UDS of asymptomatic men and women.DO is defined as involuntary bladder contractions on CMG. Overactive bladder is a symptom complex with the hallmark symptom of urinary urgency and is not diagnosed on UDS. Detrusor overactivity has been reported to occur in studies on asymptomatic men and women. Impaired compliance, not DO, is associated with renal deterioration. DO is an observation made during urodynamics.
6. c. High pressure–low flow voiding dynamics. Obstruction is defined by high pressure low flow voiding.It may or may not be accompanied by incomplete bladder emptying. Impaired detrusor contractility may sometimes, but not always, be a long-term consequence of obstruction.
7. b. Relax prior to a voluntary detrusor contraction in a neurologically normal person. In a neurologically normal person, the external sphincter progressively contracts with bladder filling and will also contract during an involuntary bladder contraction (guarding reflex). External sphincter relaxation is the first step in the micturition cycle and precedes the detrusor contraction.In detrusor external sphincter dyssynergia, an abnormal neurologic condition, the external sphincter contracts when the detrusor does. Intermittent or fluctuating flow rate of urine due to intermittent contractions of the external sphincter in a neurologically normal person is considered dysfunctional voiding.
8. c. Is the procedure of choice for documenting bladder neck dysfunction in men and women.Although VUDS provides the most precise evaluation of voiding function and dysfunction and is particularly useful when anatomic structure and function are important, it is not practical or necessary for all centers to have VUDS capabilities. VUDS is useful for a number of conditions when an accurate diagnosis cannot otherwise be obtained (e.g., by conventional UDS) including complicated voiding dysfunction or known or suspected neuropathic voiding dysfunction (adults and children), unexplained urinary retention in women, prior radical pelvic surgery, urinary diversion, preceding or following renal transplant, or prior pelvic radiation. VUDS is the procedure of choice for documenting bladder neck dysfunction in men and women. VUDS is not specifically needed to diagnose DO.
9. d. Should not be used as a single factor to grade the severity of incontinence.Urethral function tests such as ALPP and MUCP have not been shown to be consistently useful in defining "ISD" or outcomes of treatments for SUI. They may be useful for some clinicians, but are by no means mandatory. According to the International Continence Society, "Urethral function measurements of leak point pressures and urethral closure pressures are not used as a single factor to grade the severity of incontinence." UDS is not necessary before surgical treatment of SUI for all women, but if it is done, the AUA/SUFU Guideline states that ALPP or MUCP should be preformed. ALPP can be reported as part of ambulatory UDS; however, it is not a measure that is unique to this method.
10. c. Presence of vesicoureteral reflux.Bladder outlet obstruction and radiation can cause a decrease in compliance, but should not affect its accurate measurement. GU TB also can cause significant bladder fibrosis and impaired compliance. Reflux can make compliance look worse that it actually is secondary to the "pop-off" it creates. Fluoroscopy or VUDS is necessary in some cases (e.g., neurogenic bladder) to assess for reflux during filling. In addition, filling rate and involuntary detrusor contractions can also make compliance look worse than it actually is. There are no data to support the proposition that fluid-filled catheters or air charge catheters will result in inaccurate measures of compliance, which is a measure of change volume over pressure.
11. c. Failure to store secondary to an underactive bladder outlet.Stress incontinence is a symptom caused by failure to store urine during increases in abdominal pressure. It can be caused by a loss of outlet resistance or an underactive bladder outlet.
12. a. Rectal or vaginal catheter pressure.Rectal and or vaginal pressure are used to measure abdominal pressure throughout UDS. Patients who are straining to void will exhibit increases in abdominal pressure measurements. Flow patterns can be suggestive of abdominal straining, but are not as accurate as measuring abdominal pressure. Postvoid residual may allow clinicians to understand how well the patient is emptying his or her bladder but does not give information about how voiding is accomplished. Similarly, EMG may be increased from abdominal straining, but there are many other causes of increased EMG activity during voiding. Bladder catheter pressure will increase with abdominal straining. The difference between the bladder catheter and the rectal or vaginal catheter allows for calculation of the detrusor pressure.
13. a. In women who are considering surgical correction who also have urgency incontinence symptoms or difficulty emptying the bladder.UDS in women with pure stress or stress-predominant mixed incontinence and normal emptying has not been shown in randomized controlled trials to be more beneficial than office evaluation alone and has not been shown to predict outcomes of surgery in the same population. Women with significant mixed incontinence and emptying problems have not been studied in randomized controlled trials, and it is felt that UDS is beneficial in these women.

Chapter review

1. UDS is performed in an unnatural setting and therefore does not always predict the findings with normal activity.
2. Normal uroflow is a bell-shaped curve.
3. EMG patch electrodes measure perineal muscle function with the assumption that it is reflective of urethral external sphincter function.
4. To specifically measure external sphincter function, needle electrodes must be used.
5. Mean values for compliance are 40 to 120 mL/cm H₂O.
6. Measurement of compliance is difficult to interpret; therefore, pressures during filling are more often used to predict outcome.
7. There are two types of leak-point pressures: (a) abdominal leak-point pressure, which is defined as the intravesical pressure at which urine leakage occurs due to increased abdominal pressure; and (b) detrusor leak-point pressure, which is a measure of detrusor pressure at which urine leakage occurs in the absence of a detrusor contraction or increased abdominal pressure. This measure is generally used in patients with decreased compliance or lower motor neuron disease.
8. Detrusor pressures that are sustained above 40 cm H₂O lead to deterioration of the upper tracts.
9. Maximum urethra closure pressure is defined as the difference between peak urethral pressure and intravesical pressure and is normally between 40 and 60 cm H₂O.
10. Bladder outlet obstruction index is defined by the equation: BOOI = Pdet Qmax − 2(Qmax). In men, a value greater than 40 is considered obstructed; a value less than 20 is considered unobstructed.
11. A uroflow less than 12 mL/sec and Pdet greater than 25 cm H₂O predicts outlet obstruction in women.
12. Detrusor external sphincter dyssynergia can be due to a neurologic lesion (above the sacral micturition center) or a learned disorder. The latter is considered dysfunctional voiding.
13. Internal sphincter dyssynergia must be diagnosed by VUDS.
14. Stress incontinence, which is observed only when a coexisting prolapse is reduced, is referred to as occult or latent stress incontinence.
15. For internal sphincter dyssynergia to occur, the spinal cord lesion must be above the sympathetic outflow (T-10-L-1).
16. Videourodynamics is the procedure of choice for documenting bladder neck dysfunction in men and women.
17. In a neurologically normal person, the external sphincter progressively contracts with bladder filling and will also contract during an involuntary bladder contraction (guarding reflex). External sphincter relaxation is the first step in the micturition cycle and precedes the detrusor contraction.