Diagnostic Evaluation of Lower Urinary Tract Symptoms in Women

1. Diagnostic Evaluation of Lower Urinary Tract Symptoms in Women Jeffrey P. Weiss, MD, FACS Professor and Chair Department of Urology SUNY Downstate College of Medicine VA NY Harbor Healthcare System Brooklyn, NY

2. Lower Urinary Tract Symptoms (LUTS) • Storage symptoms(irritative symptoms) • Emptying symptoms (obstructive symptoms)

3. Storage Symptoms • Urinary Frequency • Urgency • Nocturia • Incontinence • Pain

4. Voiding Symptoms • Hesitancy / Weak Stream / Straining • Incomplete emptying • Urinary Retention • Pain

5. Pain • Dysuria • Perineal “Aching” • Inner Aspect Of Thighs • Suprapubic Fullness

6. Conditions causing symptoms • Urethral obstruction • Impaired detrusor contractility • Detrusor overactivity • Low bladder compliance • Sensory urgency • Learned voiding dysfunction • Polyuria

7. Differential Diagnosis • OAB • Pelvic prolapse • Urethral stricture • Neurogenic voiding dysfunction • Urethral diverticulum • Acquired voiding dysfunction • Diabetes insipidus

8. Remediable Conditions • Storage • Sphincteric incontinence • Fistula • Overactive bladder • Voiding • Prolapse • acquired voiding dysfunction • urethral diverticulum • urethral stricture • primary bladder neck obstruction

9. Evaluation • History & physical exam • Questionnaire • Urinalysis & culture • Voiding diary

10. Physical Examination • General • Urologic • Neurologic • Neuro-urologic

11. Physical Examination • General • Cognitive function • Signs of CHF • Peripheral edema • Urologic • Exam with full bladder for SUI • Pelvic prolapse: location • Palpable urethral mass • Vaginal mucosal health

12. Physical Examination • Neurologic • Cognitive function • Gait • Muscular strength • Deep tendon reflexes • Neurourologic • Perianal sensation • Anal sphincter tone & control • Bulbocavernosus reflex

13. Bladder Diary • Essential component of the w/u • Time & amount of each urination • Description of symptoms • +/- oral intake • The diary is a snapshot to becompared to day to day sx

14. Voiding Diary

15. Pad Test • Useful for quantifying the amount of urine loss – two kinds: • Stress pad test (20 min – 1 hour)(to provoke incontinence) • 24 hour – 3 day – 7 day pad test( to mimic typical day)

16. Evaluation • Q & PVR • Urodynamics • Cystoscopy • Upper tract imaging Renal ultrasound CTU

17. Uroflow • Functional evaluation of interactionbetween the bladder & urethra • Low flow: bladder outlet obstruction impaired detrusor contractility • Normal flow: does not exclude obstruction

18. Uroflow Normal ml/S Obstructed Impaired contractility Acquired voiding dysfunction 20 10 Seconds

19. Post Void Residual Urine • Ultrasound • Catheterization • Contrast imaging study

20. Post Void Residual Urine • An elevated PVR means that the bladder did not contract strongly enough for that urethra during that particular micturition • It does not necessarily mean thereis bladder outlet obstruction • A low PVR does not exclude urethralobstruction • Highly variable and should be repeated

21. Upper Tract Imaging(indications) • Significant urethral obstruction • Detrusor sphincter dyssynergia • Low bladder compliance • Adult onset enuresis • Women with LUTS & low Q whodon’t want RX

22. Indications for Cystoscopy* • hematuria • sterile pyuria • pelvic/bladder/urethral pain • vesicovaginal fistula • extra-urethral incontinence • I do cystoscopy preoperatively on all patients including prolapse • To be sure there are 2 ureteral orifices • No surprises 4th ICI, 2008

23. Urodynamics: Purpose • Reproduce symptoms • Diagnose pathophysiology of underlying symptoms • Identify risk factors • Direct treatment • Prognosticate

24. Urodynamics • An interactive test between patient & physician • The findings must be interpreted at the time of the study • It is not possible to interpret the study by looking at the tracings afterwardsunless there has been a detailed annotation

25. Prior to Urodynamics • What are the symptoms? • Was SUI or prolapse found on exam? • Neurologic lesion? • Bladder capacity (MVV) • Q & PVR • Formulate questions to be answered by the study

26. Indications for Urodynamics • Low uroflow • High PVR • Uncertain diagnosis • Finding that requires further evaluation • Persistent symptoms despite apparently appropriate treatment

27. Storage Phase Urodynamics • Cystometrogram (CMG) • Leak Point Pressure • Urethral Pressure Measurements • EMG • Cystogram

28. Emptying Phase Urodynamics • Detrusor pressure – uroflow study • Micturitional urethral pressure profile • Sphincter electromyography (EMG) • Post void residual • Voiding cystourethrogram

29. Cystometry (CMG) • Measurement of bladder pressure and volume during bladder filling: • Bladder sensations • Bladder pressure • Involuntary bladder contractions • Bladder compliance • Bladder capacity • Control over micturition

30. Cystometry • Once aware, can she contractthe sphincter ? • Does sphincter contraction abort the stream? • Does sphincter contraction abortthe detrusor contraction?

31. Idealized CMG Storage Voiding pdet Volume

32. Videourodynamics • Combines urodynamics with fluoroscopic imaging of the LUT during • bladder filling • provocative maneuvers • voiding • Most accurate means of assessment

34. (Voiding) Detrusor PressureUroflow Study • Urethral obstruction = high detrusor pressure & low uroflow • Impaired detrusor contractility = low or poorly sustained detrusor pressure& low flow

35. 2 Strss Low flow High pressure

36. Low flow Low pressure JK

37. Evaluation of Incontinence • HX, PE (observation of SUI, prolapse) • UA • Q-tip test • Bladder diary (incontinence episodes) • Pad test • Q & PVR (straining pattern)

38. Conditions Causing Incontinence • Bladder problems • Detrusor overactivity • Low bladder compliance • Fistula • Sphincter problems • Urethral hypermobility • Intrinsic sphincter deficiency

39. Q-tip Test Cough or strain > 30O = hypermobility

40. Vesical Leak Point Pressure(VLPP) • The bladder is filled with 150 ml • The patient coughs or strains • VLPP = Pves at leakage • Low VLPP = intrinsic sphincter deficiency A means of quantitating intrinsic sphincter strength

41. Cough Rwn No leak

42. Cough Rwn leak VLPP VLPP = 45 cm H20 Qtip = 0 > 10O

43. Mixed Stress & Urge Incontinence • Difficult diagnostic problem • “If I wait too long, I leak…” • Relative severity of each • Differential diagnosis: • Stress hyperreflexia • SUI & DO • SUI & sensory urgency

44. Rbn VLPP = 60 Voi Involuntary detrusor contraction Incontinent

45. Formulating a Treatment Plan • Diary • Pad test • Patient activity level & lifestyle • VLPP • Q-tip angle • Bother index • Patient preferences

46. Urodynamic Diagnoses • Urethral obstruction • Impaired detrusor contractility • Detrusor overactivity • Low bladder compliance • Sensory urgency • Learned voiding dysfunction

47. Female Urethral Obstruction • High detrusor pressure: Pdet@Qmax > 20 cm H20 • Low uroflow: Qmax < 15 ml/S • Site of obstruction = narrowest point of urethra during voiding

48. Urethral Obstruction: 5 Main Causes in Women • Pelvic prolapse • Urethral diverticulum • Urethral stricture • Bladder neck obstruction • Pelvic floor dysfunction • DESD

49. Free Flow Qmax (ml/S)

50. Urodynamic Diagnoses • Urethral obstruction • Impaired detrusor contractility • Detrusor overactivity • Low bladder compliance • Sensory urgency • Learned voiding dysfunction