Urodynamics - Bon Secours Health System

Urodynamics - Bon Secours Health System

Urodynamics What is it? An overview Phil OLoingsigh Definition Urodynamics is the study of pressure and flow relationships during the storage and transport of urine within the urinary tract

Chapple, MacDiarmid and Patel 2009 Urinary System Male Female Bladder Male

Female Optimal Function of Lower Urinary Tract Storage Voiding Low Pressure

Stable Bladder Adjustment of sphincter// End Filling desire to void Empty of Upper Urinary Tract Low pressure in Upper Urinary Tract Voluntary Start Powerful stream No Post Void Residual

Coordination of detrusor-contraction and relaxation of pelvic floor Capable of interruption of flow Investigations Frequency/Volume Chart Filling Cystometry Urethral Pressure Profile

Investigations Frequency/Volume Chart Uroflow Full Urodynamic Study Urodynamic Tests Uroflow Studies Full Urodynamic Study

Urethral Pressure Profile Reasons for performing Urodynamics Voiding Problems Storage Problems Benign Prostatic Hypertension-BPH Pelvic Organ Prolapse-POP

Urethral Strictures Pelvic Floor Dysfunction Detrusor Sphincter Dyssynergia Hypocontractile Bladder (residue formation and recurrent UTIs) Neurogenic Bladder OAB wet (Sensory urge)-incontinence OAB Dry (Sensory urge) - Reduced

Capacity Bladder Outlet Obstruction - BPH POP Pelvic Organ Prolapse Stricture Reduced Compliance Reflux Bladder Ca Interstitial Cystitis and other bladder inflammatory conditions

Spinal Cord Lesion can cause: Storage Problems T11-L2 Voiding problems S2 S4 Why choose a Urodynamic Study? Urodynamics Investigations should only be performed if it would influence the treatment or therapy for the patient

Objectives : to diagnose Storage or Voiding Problems Control Treatment Efficacy : Neurogenic Bladder If therapy fails and there is doubt as to the underlying cause of Lower Urinary Tract Symptoms Full Urodynamic Study is an Invasive Investigation Other Tests

History Frequency/ Volume Chart International Prostate Symptom Score - IPPS Physical Examination Digital Rectal Exam (DRE) MSU (Clear) Cystoscopy Radiological exam - U/S, CT, MRI

Urodynamics Department Situated in OPD Urodynamics MMS Machine Commode and Flowmeter Remote Flowmeter Bladder Scanner

Remote Flowmeter Uroflow Investigation The aim is to get a typical flow for the patient albeit in a strange environment Discuss the patient history and explain the procedure carefully Frequency Volume Chart IPSS Score (Male)

Uroflow - When patient has good urge to void, fully empties into a collection funnel which is attached to the computer. Post Void Residual Scan (PVRS) U/S Scan Performed Twice as minimum Frequency Volume Chart Frequency/ Volume Chart

Mostly assesses storage problems Urgency/Frequency Nocturia Pain

Incontinence frequency and severity Grade 1-3 Functional bladder capacity - large/small Fluid Intake large/small International Prostate Symptoms Score - IPSS Normal Flow

52yr old Male PVRS 5mls Uroflow

Look at Qmax and Curve and residual Is the voided volume representative? >150mls and ask the patient if the flow is normal for him Artefacts (void outside the funnel) Interpretation of curve (fluent, intermittent or elongated )

Interpretation of Qmax in cmsH2O Man Normal young - 25 Over 60yrs -15 Woman Normal young 25 35 Over 60yrs 25 Assess post void residue especially in

patients with UTI problems Flow Traps Not Natural

Need to be repeated Take into consideration Frank Sterling Law Low bladder volume <150mls not representative High bladder volume (overstretched bladder) Post Void Residual Scan This Ultrasound Scan is performed immediately after the flow.

Ask if that was a typical flow for the patient and whether they feel empty post flow. Normal PVR < 40 mls The aged bladder can have larger residuals > 100mls. ( Check Kidney function prior to Rx) Post Void Residual Scan Intermittent Flow

26yr old female Uncontrolled IDDM Recurrent UTIs PVRS 375 mls Cystoscopy showed Uretheral Stricture Rx Uretheral dilatation and CISD Clean Intermittent Uretheral Dilatation Restricted Flow 74 yr old male with Benign Prostate Hyperplasia (BPH) IPSS -18 QOL - 4 PVRS 3mls

Restricted Flow ( Elongated) 90yr old male TURP 20-25yrs ago IPSS 29 QOL-5 PVRS 277mls Nocturia x 5 Rx options Conveen continence system, long-term catherisation or Repeat TURP Full Urodynamic Study Filling Cystometry filling sensations, adequate

Stress Tests, adequate monitoring of Detrusor Overactivity Pressure Flow good posture, full bladder, good timing of voiding command Urethral Pressure Profile (UPP) - Females Resting and Stress Profile Test Quality Depends on the skill and knowledge of the performer and its supervision

T raining and supervision Training must initially be given under the supervision of an identified preceptor. This should normally be for a minimum of 20 sessions if 34 patients are seen per clinic. It is anticipated that this would involve attending a regular clinic for a period of 6 months. Within the first 12 months of commencing practical training, the trainee should attend a relevant theoretical course. Written evidence of observations of clinical practice and formal testing of a minimum of 30 cases must be undertaken and completed to the satisfaction of

preceptor before the trainee is deemed competent to practice unsupervised. Attendance at a regular MDT meeting to present and discuss interesting or challenging management of cases seen. Joint statement on minimum standards for urodynamic practice in the UK April 2009 To enhance Quality one needs: Up to date knowledge of Lower Urinary Tract function and disease

Technical knowledge of the equipment Use/develop protocols for Urodynamics Regular discussion of Urodynamic Results with colleagues /supervisor Placement of catheters Bladder probe -double lumen catheter Bladder - Vescicle Pressure P(ves) Rectal Probe placed into rectum

Abdominal Pressure P(Abd) Test by asking patient to squeeze buttocks Urodynamics Set Full Urodynamic Study Post Uroflow a catheter is passed into bladder to remove the residual urine so the test starts with a completely empty bladder.

Zero transducers to air at level of Symphysis Pubis Filling Cystometry Cough before start and every 50mls while filling mark if leak yes/no ICS 2002 definition of sensations ICS 2002 Definition of Sensations

First sensation First desire to void Normal desire to void Strong desire to void Urgency

Full Urodynamic Study Filling Cystometry

Valsalva test at 200mls and at capacity Stop pump if patient has detrusor contraction Stand patient if needed for cough tests and valsalva Fill until strong desire or max capacity Fill until 500mls unless patient shows large capacity on F/V chart Full Urodynamic Study Pressure flow study

Coupled with Cystometry Void on nurses command Try not to start void during detrusor contraction Patient empties fully Full Study - Normal 41yr old female, Para 3, Mild Stress Incontinence

Detrusor Overactivity 70 yr old IDDM male with LUTS IPSS -18 Rx Medication +/- TURP Detrusor Overactivity with Stress Induced Contractions 39yrs old Female with Mixed Incontinence

Compliance Reduced in Neurogenic patient with long-term Detrusor Overactivity and Detrusor Sphincter Dyssynergia Reduced post radiation of prostate Normal compliance < 5cmH2O increase over 100mls

Poor Compliance 63yr male c/o Frequency and Urgency, not feeling empty post void. Uretheral Pressure Profile Measures the length of the Urethera and the Detrusor Sphincter Pressure. Used to diagnose Detrusor Sphincter Insufficiency < 20mmH2O.

Uretheral Strictures Important pre op study for Colpo- suspension (Sling Op) Normal Urethral Pressure Profile 53yr old Uretheral Length 2.5 cms Maximum Uretheral Closure Pressure 62 cmH2O

Stress Urethral Pressure Profile 67yrs with hx of Stress Incontinence X 1-2 years Hysterectomy 20 yrs ago Urethral Length 3cms Maximum Urethral Closure Pressure 24 cmH2O Post Procedure Advise patient that they may see some blood stain as they Pass urine. Drink extra water to flush it out

3% of patients develop UTI advise to go to GP for antibiotics if symptomatic Patients can contact Urodynamics Dept for any concerns In Practice MSU 10 days a week prior to Study and results faxed to OPD 0214342093 Frequency Volume Charts

Michigan Incontinence Symptom Index IPSS Sources of Information www.ic-network.com www.ics.org www.iaun.ie Company Nurse Advisors Hollister, BBraun, SCA Hygeine (Tena)

Urodynamics department BSH 0214801942 THANK YOU

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