1 / 57

Urodynamic assessment in women with urinary incontinence

Urodynamic assessment in women with urinary incontinence. Zahra jabbari khanbeben Imam khomeini hospital. Definition and type of urinary incontinence. UI is defined as involuntary leakage of urine that can affect on health- related quality of life

doris
Download Presentation

Urodynamic assessment in women with urinary incontinence

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Urodynamic assessment in women with urinary incontinence Zahra jabbari khanbeben Imam khomeini hospital

  2. Definition and type of urinary incontinence 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

  3. Assessment of urinary incontinence History Dairy chart Urinalysis Physical exam Q tip test Estimation of post void residual Cough stress test Pad test Urodynamic study

  4. Criteria for advance Urodynamic Evaluation (Multichannel ,Urethral Pressure Profile,Videourodynamics &Ambulatory Urodynamics) • 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

  5. Introduction • 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

  6. اهداف مطالعات یوروداینامیک هدف اصلی ایجاد علایم و شکایات بیمار است تا با به دست اوردن مقادیر فیزیو لوژیک بتوان پاتو فیزیو لوژی نشانه های بیماری را ارزیابی کرد. این تست فاکتورهای فیزیولوژیک و پاتولوژیک دخیل در ذخیره و تخلیه ادرار را بررسی و ارزیابی میکند یوروداینامیک جایگزین هیچیک از روشهای دیگر ارزیابی نیست. تستهای اصلی یوروداینامیک شامل :یوروفلومتری سیستومتری upp

  7. Common Urodynamic Tests • 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)

  8. Clinical roles • 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

  9. Routine Urodynamic Duet Logic • 4 pressures • EMG channel • Flowmeter • Puller • Water/gas pump • Windows

  10. Uroflowmetry 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.

  11. Uroflowmetry • 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/sec Women >20cc/sec • Mean flow rate (Qave) should be 50% of Qmax • Specific to age and gender

  12. The patient • 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

  13. Vura Qura Urodynamic Equipment Recording Flow Flow Transducer UroflowmetryUrodynamic Equipment I’m relaxed and voiding in privacy

  14. Uroflowmetry(cont.) • 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

  15. Time to 100 ml Vura ml 100 Voided Volume (Qmax) Maximum Flow Rate Voided Volume (Qave) Average Flow Rate Voided Volume / Flow Time Qura ml/s Time s (TQmax) Time to Max. Flow Flow Time Voiding Time Uroflowmetry Parameters

  16. Flow Rate ml/s Delay Time s 2.5 Max. Flow Rate ml/s 23.5 Time to max. Flow s 3.5 Flow Time s 11.3 Voiding Time s 13.5 Voided Volume ml 120 Average Flow Rate ml/s 10.6 Residual Volume ml 90 20 10 Time s Results Urodyn 1000

  17. Maximum Flow Rate Value (Qmax) It is the most important single parameter in flowmetry. Its interpretation requires familiarity with: Flow curve pattern - voided volume - age and sex MaleQmax  15 ml/s 70-90% non-obstructed Qmax  10 ml/s 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 Lower limit Qmax  40 ml/s Decreased urethral resistance (Bladder base insufficiency)

  18. Normal Flows

  19. Low Flows

  20. Intermittent Flows

  21. Healthy Benign prosthetic hypertrophy Qura Qura Time Time Urethral stricture Cystocele Qura Qura Time Time Vesico-Sphincter Dyssynergia Bladder neck rigidity Qura Qura Time Time FlowTypical curves & Pathologies

  22. Residual urine volume • 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

  23. Cystometry 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

  24. Methods • Filling • Water Cystometry, urethra-cystometry • Gas Gas-cystometry • Pressure Measurement • Water Water filled catheters + pressure transducersMicro-tip catheters • Gas Folley catheter

  25. Test 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 cmH2O/ Div.

  26. Pabd Pdet Pves Pura EMG Qura Urodynamic Nomenclature Pabd = Abdominal Pressure Pves = Vesical Pressure Pdet = Detrusor Pressure Pura = Urethral Pressure Pclos = Closure Pressure Qura = Urinary Flow EMG = Electromyography Pdet = Pves– Pabd Pclos = Pves – Pura

  27. Signal Testing Before Study • Zero pressure to atmosphere • Turn tap open between transducer and patient • Initial resting pressures for Pves and Pdet • supine – 5-15 cmH20 • sitting – 15-40 cmH20 • standing – 30-50 cmH20 Initial pressure should be 0-6 cmH20 (80%)

  28. Pura Don't forget to open Pura perfusion! 1000 ml STERILE WATER BAG Pves Pabd Pdet Catheters Recording bladder and urethral pressure reactions during filling with control of abdominal pressure Pump Pves Pura Pabd Pressure Transducers Perfusion Set Water Urethra-Cystometry

  29. V2 - V1 Compliance = P2 - P1 EMG Pura Pves Pabd Pdet Qura Vinf P2 P1 Time 1 min/Div 0 100 200 300 400 500 600 ml V2 V1 Filling at 50 ml/ min. Cystometry + LPP UU Cough Cough Cough RH Speaking Urgency & Maximum Capacity Strong Desire 350-400 ml Normal Desire 250-300 ml First Desire 150-200 ml Basic Pressure Leak Point Pressure Compliance Compliance NIDC Leak UR MCC SD FD ND 20 ml RH = Rectal Hyperactivity NIDC = Non-Inhibited Detrusor Contraction UU = Unstable Urethra

  30. Interpretation of Results: “3C’s” and “2S’s” Capacity Compliance Competence Sensations Stability

  31. Bladder Capacity ml I’ve a First Desire. It’s still a passive desire. At home, I would go to toilet. Here I can wait. I’ve got to go but I contract my sphincter to finish what I’m doing. I go to the toilet immediately before I leak. First Desire FD Normal Desire ND Strong Desire SD Urgency UR 150 - 200 250 - 300 350 - 400 Voluntary Contraction > 500 Desire to Void

  32. Compliance • 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/cmH20 • Ability of bladder wall to distend • EFP below 15 cmH20 (usually less in females) • Pdet of 40cmH20 or > - high risk to upper tract

  33. Competence of the Sphincter • 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

  34. Competence of the Sphincter • 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

  35. Sensations • 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

  36. Stability • 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

  37. Normal Values Residual Volume < 20 ml ; < 10% Voided Volume Before cystometry Compliance Basic Pressure BP < 20 cmH2O First Desire FD150 - 300 ml (H2O)< 15 Normal Desire ND< 20 Strong Desire SD250 - 400 ml (H2O)20-50 Urgency UR Cystometric Capacity MCC 300 - 600 ml Main Criteria - Detrusor Contractions = 0 - Residual Volume = 0 - Compliance = Normal - Cystometric Bladder Capacity = Normal - Normal Desire Progression (SD ml = FD ml + 100)

  38. EMG Pura Pves Pabd Pdet Qura Vinf Cough 20 ml Voiding Phase 0 180 ml Clinical Case Detrusor Instability • Maximum infusion rate 20 ml/ min. • Detrusor contraction after stimulation (cough) • Low compliance

  39. Leak Point Pressure • 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)

  40. Pabd Leak Qura Delay 0,8 s 30° Recording Abdominal or Vaginal Pressure, Leak Detection and Flowmeter VLPP Abdominal In Practice 120 120 Bladder filled with 200 ml. I push with increased force until leaking! 100 100 96cmH2O 80 80 60 60 Leak Leak

  41. Valsalva Leak Point Pressure = SUI

  42. LPP Stress Incontinence - Normal Values Normal persons do not leak at any pressure rise. Female, leakage at pressure: SLPP >90 cmH2O Mobile Urethra SLPP <60 cmH2O ISD SLPP 60-90 Equivocal Depend on history, Bladder neck… 80% of patients with SLPP <90 cmH2O have ISD Male, diagnosis of post prostatectomy incontinence.

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

  44. 55-year-old She wets with a small amount of exertion. Complication of childbirth? “Re-hitch” her bladder up? VLPP = 25 cmH2O Suggestion? Leakage seen here 60 Bladder Pressure cmH2O 40 Pressure at this point = 25 cmH2O 20 200 Infused Volume ml VLPP Clinical Cases Contemporary Urology - April 98 Julian Wan, MD VLPP = 25 cmH2O 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

  45. Leakage seen here 60 Pressure at this point = 30 cmH2O 40 Bladder Pressure cmH2O 20 200 Infused Volume ml VLPP Clinical Cases Contemporary Urology - April 98 Julian Wan, MD 65-year-old She will soon be undergoing surgery for correction of a large cystocele and rectocele. She is currently not wet. VLPP = 30 cmH2O after cystocele reduction 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.

  46. 550 290 24 35 11 12.5 MCC VE MF VB MP Pves Pabd EMG Qura Recording Bladder, Abdominal Pressure and Electromyography during Voiding phase Voiding-Cystometry

  47. EMG Pdet Pves Pabd Qura Time 30 sec/Div Voiding-Cystometry Low EMG activity during voiding = Synergy Normal Detrusor Pressure Cough Abdominal Pressure for last drops Normal Flow Rate and duration PM VB QM VE

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

  49. Atonic Bladder

More Related