Urodynamic AssessmentOfNeurogenic Bladder

UrodynamicA science concerned with storage, transportation & evaluation of urine of LUT

Rule No. IStudy Must reproduce clinical symptom So Simplest and easily reproducible least invasive Give answer (Best)

Rule No. IIUsed whenever one feel that their use Aid in patient management Blaivis (MS) 27% Vs. 83%.

Indications for urodynamic evaluation Incontinent patients BOONeurogenic voiding dysfunction Children with voiding complex

cystometry before medical treatment

Role of urodynamics Characterization of detrusor function Diagnosis and characterization of neuropathy Evaluation of voiding function Evaluation of outlet

Urodynamics Quantitative data relative to events taking place in the BIadder and the outlet Filling Emptying accommodation of volumes under low pressure no unstable waves closed outletadequate detrusor contraction Concomitant resistance (smooth & sphincteric) No anatomical obstruction

vLUTBladderOveractive Normal Under activeUrethraUnder active incompetent Normal closure mechanismsOveractive closure mechanism

Urethra Normal closure Overactive Non relaxing Dysinergic Incompetent Neurogenic Degenerative Traumatic

Detrusor Normal No unstable waves even with provocationVoid on command Sustained contraction Can be suppressed Over active Involuntary contraction Under active Non contractile Vs. areflexic No sustained detrusor contraction

Recommended international Continence socitety registration of combined pressure (S) and flow recording.

Non invasive unodynamics Mc Raeschfer Urethral cuff condom cath.?? Many controversies

40 Cm H230 Cm H240 Cm H2OMcGuive Blavis

Various representative adult cystometrograms.

UPP: TechniqueSimultaneous pressure measurment in bladder & urethera with two pressure sensors.Pulling back with constant speed ( via puller)Uretheral pressura intravesical pressure is closure pressure.Main parameters are: Maximum uretheral closure pressure (MUCP)Functional uretheral length.(FUL)Pressur transmition ratio (during cough)

UPP: TypesContinence maintained in rest by passive resistance of uretheral structures: profile in rest

The intraabdominal pressure is transmitted onto the urethera during sudden pressure increase (stress): Stress profile

UPPDetrusor overactivity -MUCP may be normal or even higher than expected. -There tends to be a normal response to stress and adopting an upright position.Detrusorsphincter dyssynergia -Instead of a drop in urethral pressures during voiding, there is an abnormal simultaneous increase

Specialized testing Provocative Pharmacologic manipulation Rapid fill cystometry (rule out areflexia) Changing position Coughing Bethanechal super- sensitivity test (BSST)Cannons low of denervation (Lapides)

BSST 1 ml/secAt volume10 ml10,20,30 min after 2.5 (or 5mg) subcutaneous 2.5 mg5 mg> 15 cm H2

Sensitivity 75%False veDecompensated Bllader. dose (0.035/kg or 5 mg)Detrusor instabilityBSSTSpecificity 50% (Blaivis)(false +ve)Infection AzotemiaDetrusor hypertrophy

RU Weak detrusor effect of ageing Infravesical obst.31% RU> 50ml* Variations ( in early morning why) * When increase RU --> 1.5% Retention / 1 year.

RU50-100ml> 3 times Repeated UTI> 300mlmay lead to UT dilat.

Residual urine Indication for surgery ?? (Chronic Retention)Progressive condition?? ill found Threatened to repeated infectionill found in Boo but evident in: SCI DiabetesChildrenDocumented relation to Renal failure (increase vesical Press.)

Residual urine Unrepresentative results: Unfamiliar environment OverdistentionPartially filled bladder Associated condition V-U reflux BI diverticulum * Bladder voiding efficiency

RUrecommendedGood flow NO RUGood flow RUPoor flow NO RUGood signNo Significance No Significance 1/2 non obst-elderly --> RU. 1/3 of obst. Pat. --> RUpoor prognostic indicator of Boo Complications. Weak association with the Boo

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