Estandarización y control de calidad en los estudios urodinámicos

The main purpose of urodynamic studies is to reproduce the patient’s symptoms and correlate them with the findings in the examination, so that we can answer the specific question that motivated it. Its success depends on a careful tuning of equipment and strict quality control over each of the procedures. In this article we refer to standards and best practices for measurement and quality control of uroflowmetry, filling cystometry and voiding cystometry (pressure-flow study), following the nomenclature and suggestions of the International Continence Society (ICS). This organization recommends a careful and continuous observation of the signals as they are obtained and an ongoing assessment of the credibility of them, so as to avoid artifacts which must be corrected immediately, as it is always difficult and often impossible to correct them retrospectively. Only in this way can we achieve our goal

Perfil de presión uretral

The “urethral pressure profile” is a graph indicating the intraluminal pressure along the length of the urethra and the “urethral closure pressure profile” is given by the substraction of intravesical pressure (pves) from urethral pressure (pura). Both aim to represent the ability of the urethra to prevent involuntary leakage of urine on efforts or exertion. The continuous measurement of pves also allows the detection of detrusor contractions. In this article we will refer to its terminology, the necessary equipment to carry it out, the examination technique, its morphology in women and men, and the stress urethral pressure profile in women. The most important parameter is the “maximum urethral closure pressure”, which is the maximum difference between pura and pves; a value ≤ 20 cm H2O participates in the urodynamic definition of intrinsic sphincter deficiency (together with an abdominal leak point pressure ≤ 60 cm H2O). However, it must be taken into account that the different techniques used for its measurement has led to inconsistent results, which makes their acceptance in clinical practice difficult

Infección urinaria recurrente en la mujer

Resumen: La infección urinaria recurrente (ITU-R) en la mujer es un fenómeno muy frecuente que aumenta con la edad. Generalmente ocurre en pacientes sin alteraciones del tracto urinario, por lo que los exámenes de imágenes contrastados, endoscópicos y/o funcionales del tracto urinario deben reservarse a casos seleccionados. Las mujeres con ITU-R tienen una mayor predisposición a la colonización vaginal por uropatógenos que se adhieren más ávidamente a sus células epiteliales. Las relaciones sexuales frecuentes, el uso de espermicidas, el antecedente de ITU a corta edad,la historia materna de ITU y uso reciente de antimicrobianos son factores de riesgo. No se ha encontrado asociación entre ITU-R no complicada y cicatrices renales, hipertensión arterial o enfermedad renal crónica progresiva. Dentro de las terapias para la prevención de la recurrencia de efectividad comprobada se encuentran la profilaxis antimicrobiana continua y postcoital, la vacuna oral y el reemplazoestrogénico vía vaginal en la mujer postmenopáusica, siendo la profilaxis antimicrobiana la que muestra los mejores resultados. Siempre se debe tener en cuenta el daño colateral que produce la terapia antimicrobiana. El uso de vacuna vaginal y de lactobacilos vaginales se encuentra en desarrollo y sus resultados son promisorios. Tanto el uso de arándanos rojos como de ácido ascórbico no han comprobado su efectividad.Finalmente la ITU-R también puede manejarse con terapia antimicrobiana iniciada por la paciente en mujeres con buena adhesividad a las indicaciones médicas. Summary: Recurrent urinary tract infection (R-UTI) in women is a very common phenomenon that increases with age. It generally occurs in patients without alterations of the urinary tract, so that contrasted imaging, endoscopic and / or functional tests of the urinary tract should be reserved for selected cases. Women with R-UTI have an increased susceptibility to vaginal colonization with uropathogens due to a greater propensity for them to adhere to their epithelial cells. Risk factors include frequent sexual intercourse, spermicide use, first UTI at an early age, maternal history of UTI and recent use of antimicrobials drugs. No association has been found between uncomplicated R-UTI and renal scars, hypertension or progressive chronic kidney disease. Among the therapies for the prevention of recurrence of proven effectiveness are continuous and postcoital antimicrobial prophylaxis, oral vaccine and vaginal estrogen replacement in postmenopausal women, with antimicrobial prophylaxis showing the best results. The collateral damage caused by antimicrobial therapy should always be taken into account. The use of vaginal vaccine and vaginal lactobacilli are in development and its results are promising. The use of cranberries and ascorbic acid have not proven their effectiveness. Finally, R-UTI can also be effectively managed with self-start antimicrobial therapy in women with good adherence to medical indications. Palabras clave: Infección urinaria recurrente, mujer, patogenia, prevención, Keywords: Recurrent urinary tract infections, woman, pathogenesis, preventio

Giant Lithiasis in a Female Urethral Diverticulum

The formation of gallstones in a urethral diverticulum is a rare clinical entity and is usually seen in males. The case of a 50 year old woman is presented, who consults for hard vaginal mass and dispareunia associated with repeated urinary infections, with radiological images and an interesting photoendoscopic vision of the upper dome of the gallstone. The diverticulum was approached via vaginal way and the local extraction was successful

Differences in urodynamic voiding variables recorded by conventional cystometry and ambulatory monitoring in symptomatic women

Objectives To determine whether there are differences in pressure and flow measurements between conventional cystometry (CONV) and ambulatory urodynamic monitoring (AMB) in women with overactive bladder syndrome and urinary incontinence. Materials and Methods Retrospective study which included female subjects who underwent both CONV (with saline filling medium) and AMB, separated by less than 24 months, not using medication active on the lower urinary tract and without history of prior pelvic surgery. Both tests were carried out in compliance with the International Continence Society standards. The paired Student’s t test was used to compare continuous variables. Bland-Altman statistics were used to assess the agreement of each variable between both studies. Results Thirty women with a median (range) age of 50 (14 - 73) years met the inclusion criteria. AMB was carried out at a mean (SD) of 11 (6) months after CONV. Measurements of pves and pabd at the end of filling, and Qmax were significantly higher from AMB recordings. There were no differences in pdet at the end of filling, pdetQmax or pdetmax during voiding, nor significant difference in Vvoid. Conclusions We provide previously undocumented comparative voiding data between CONV and AMB for patients who most commonly require both investigations. Our findings show higher values of Qmax but similar values of pdetQmax measured by AMB which may partly reflect an overall lower catheter caliber, physiological filling but perhaps also more ‘normal’ voiding conditions

Evaluación clínica del paciente con síntomas del tracto urinario inferior

Lower urinary tract symptoms are divided into three groups, storage, voiding and post micturition symptoms. Their level of agreement with urodynamic investigation is poor. Clinical history should be complemented by the application of validated symptom questionnaires and the recording of urinary events. Here we refer to: a) the International Consultation on Incontinence Questionnaire, Short Form (ICIQ-SF), b) the Urogenital Distress Inventory - Short Form (UDI-6) and Incontinence Impact Questionnaire – Short Form (IIQ-7), c) the urinary incontinence Severity Index and d) the American Urological Association Symptom Index. The recordings of urinary events can be done in three main forms: a) micturition time chart, b) frequency volume chart, and c) bladder diary. The International Consultation on Incontinence Questionnaire bladder diary (ICIQ bladder diary) is the only one validated. Physical exam should include abdominal and genital examination, covering pelvic organ prolapse quantification in women, prostate evaluation in men, pelvic floor muscle function evaluation in both genders, and a neurologic examination focused on evaluation of the sacral nerves. It is useful to supplement the physical examination with the evaluation of the mobility of the bladder neck and proximal urethra through the Q-tip test, and with the quantification of urine leakage through the pad tes

Indicaciones de estudio urodinámico

The basic objective of urodynamics is to reproduce the patient’s symptoms while evaluating the lower urinary tract directly, with objective quantification of parameters, correlating the symptoms with the findings of the test. Traditionally, it is used: a) to diagnose lower urinary tract dysfunction, quantify its severity and determine the most significant abnormality, b) to predict the consequences of lower urinary tract dysfunction on the upper urinary tract, c) to predict the results of therapeutic interventions and possible complications and d) to investigate the causes of treatment failures. In this article we will refer to the indications of urodynamics taking into account the recommendations of the main international urological societies: 1) in women with urinary incontinence, with emphasis on those who have stress urinary incontinence and who will undergo surgery, 2) in men with non-neurogenic lower urinary tract symptoms suggestive of benign prostatic hyperplasia, and 3) in patients with neurologic involvement of the lower urinary tract (“neurogenic bladder”), considering the classification of neurological disorders according to the risk over the upper urinary tract

Disfunción miccional en el adulto. Un artículo docente

Voiding dysfunction is defined as an abnormally slow and/or incomplete micturition, and can be divided in bladder outlet obstruction (BOO) and detrusor underactivity (or hypocontractility). BOO is characterized by reduced urine flow rate and increased detrusor pressure, and can be of anatomical or functional origin. Detrusor underactivity encompasses a reduced urine flow rate associated to low pressure and/or poorly sustained detrusor contraction, and its etiology is multifactorial. Lower urinary tract symptoms are classified as storage, voiding and post micturition symptoms, may be objectively quantified with specific questionnaires, and don’t correlate properly with voiding dysfunction. Patients’ evaluation requires a directed physical examination of the abdomen, pelvis and genitals focused to detect anatomical and neurological abnormalities. Voiding dysfunction can be demonstrated non-invasively using uroflowmetry and pelvic ultrasound. Uroflowmetry allows determining urinary flow characteristics and their most important parameters are voided volume, maximum flow rate and shape of the curve. Pelvic ultrasound permits to estimate prostatic size and post void residual, suspect detrusor hypertrophy (due to BOO) and detect bladder stones. Invasive test must be reserved for special cases of confirmed voiding dysfunction: cystoscopy when there is concomitant hematuria, urethrocystography to study urethral stenosis and urodynamics to differentiate BOO from detrusor underactivity