SOE Urodynamics

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  • DO NOT MAKE IT DIFFICULTBy:Sunaryo Hardjowijoto, MD, PhDConsultant Urologist2006Presented at Basic Course For Surgery Trainee

  • URODYNAMICSThe study of pressure and flow relationships during the storage and transport of urine within the urinary tract.An objective investigation to clarify the symptoms.In routine practice mostly focused on the lower urinary tract.

  • Urodynamic investigations of the lower urinary tract:Investigation of bladder filling and voiding function Define bladder storage disorders Severely voiding dysfunction

  • LOWER URINARY TRACT:BladderUrethra Store urine adequatelyEmpty / expulse urine efficientlyVesicourethral unit:

  • The symptoms of vesicourethral unit dysfunction:Frequency / urgency (storage symptoms)IncontinenceSlow stream (voiding / emptying function)Urinary retention

  • The urinary bladder:Main function:Collection and low pressure storage of urineExpulsion of urine

    Made up of 3 layers:Outer: adventitial (connective tissue) layerMiddle: smooth muscle with interlacing bundleOutermost: epithelium of transitional cell

  • The urethra in male:Posterior urethra, consists of:Pars prostaticaPars diaphragma

    Anterior urethra, consists of:Pars bulbosaPars pendularis

  • The posterior urethra is utmost important for sphincteric mechanism:A proximal sphincter/bladder neck mechanismThe distal sphincter mechanism

    In females:Bladder neck is weakerUrinary continence in women relies upon the integrity of intrinsic urethral sphincteric mechanism

  • Innervation of vesicourethral units:

  • The function of vesicourethral units:Storage of urine from the kidneysExpulsion of urine from the bladder

  • Urine storage:Intrinsic factor of bladder and urethra:Tonus of the muscle and connective tissue:Urethra: keeps the wall in apposition continenceBladder walls: exhibit receptive relaxation expands w.o. increasing pressure

    Neural control:Stretch receptors posterior root of spinal cord lateral spinothalamic tracts brain (pontine micturition centre) desire to void

  • Expulsion of urine:Bladder filling reach the threshold (bladder capacity) afferent activity awareness of full bladderInitiation of voiding:Under the influence of pontine micturition centreRelaxation of: urethra pelvic floor muscles Funneling of the bladder neckProceed with detrusor contraction which is controlled by para sympathetic pathwayEnd of voiding closing of proximal urethra

  • In normal condition:Bladder capacity: 300 500 mlBladder filling pressure: 0 20 cmH2OBladder voiding pressure: 40 50 cmH2O (male) 30 40 cmH2O (female)Urethral closing pressure: 40 cmH2OUrethral voiding pressure: 0 - 20 cmH2O

  • Disorders of vesicourethral unit:Disorders of sensation:HypersensitiveHyposensitiveAbsent

    Terminology of sensation:First sensation of fillingFirst desire to voidStrong desire to voidPain during filling or micturition

  • Disorders of vesicourethral unit:Disorders of motoric function:UnstableOveractiveUnderactiveAcontractile

  • Dysfunction of bladder outflow:Incompetent leakage w.o. detrusor contractionObstructive: overactivity mechanicalDyssynergia

  • Urodynamic techniques:Volume voided chartsPAD testingFlow rateIntravenous urodynamogramCystometryVideocystometrographyUrethral pressure measurementAmbulatory urodynamicsNeurological investigationWhitaker test

  • Volume voided charts:Volume/frequency chartVoiding diaryA simple noninvasive toolIts helps to:Define severity of symptomsObjectivize the history

  • Volume voided charts:Volume/frequencey chartVoiding diary

  • PAD testing:A simple noninvasive objective method for detecting and quantifiying urine leakageThe pad is weighed before and after test period (bending and could be extended)Test schedule:Start without voiding before Wear padFirst hour:Drink 500 ml within a short periodSit/rest 15 minsWalk 30 mins, climb stairsStand up from sitting 10 XHard coughing 10 XRun 1 minBend to pick up something on the floorWash hand in running tap waterAfter 1 hour pad is removed and weighedTest positive is uncreased 1,4 g/hour

  • Flowrate (= Flowmetry)Simplest and most often done investigation to assest voiding dysfunctionA noninvasive examinationTo confirm the presence of B.O obstructionResult of examination is influenced by:Detrusor contractilityRelaxation of sphincterPatency of the urethra

  • The FlowmeterA device that measures and indicates quantity of fluid passing through the machine per unit timeTypes of flowmeters:Rotating diskElectronic dipstickGravimetricThe expressed unit: ml/s

  • The important parameters:Volume voidedRate: maximal averagePattern:ContinousNormalFastProlongedIntermittent

  • Flow rate are influenced by:Volume voided: > 150 ml - < 600 mlAgeSexSurroundings

  • The Terminology in Flow Rate:Voided volumeMaximum flow rate (Q max)Average flow rateFlow time (T)T to Q maxVoiding timeIntermittent flow

  • The graphic of urine flow:

  • The patterns of flow rate

  • CystometryA method used to measure the relationships between pressure and volume of the bladderMeasurement of detrusor pressure during filling and voidingCould assess:Bladder complianceSensationStabilityCapacity

  • Normal cystometrogram

  • Video cystometrography

  • The radiologic examination provides additional information on:The bladder anatomyThe presence of V.U. refluxThe level of outflow obstructionThe support of the bladder base during coughing