Urodynamic studies are performed as part of the clinical investigation of selected patients with lower urinary tract dysfunction. These studies provide the clinician with information about lower urinary tract function and allow a more scientific approach to the management of the individual patient. This article will concentrate on situations involving video-urodynamic studies.peer-reviewe

German,  Karl Andrew

English

German, Karl Andrew

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9 Maltese Medical Journal. 1997; 9 (I): 9 All rights reserved The use of urodynamic studies to help sort out bladder problems K. German Correspondence: K. German. Department of Surgery. St. Luke's Hospital. Gwardamangia. -, Introduction Urodynamic studies are performed as part of the clinical investigation of selected patients with lower urinary tract dysfunction. These studies provide the clinician with information about lower urinary tract function and allow a more scientific approach to the management of the individual patient. Although one might consider a simple ultrasound scan (to measure a post-micturition bladder residual) or a urine flow test study as being a form of 'urodynamic' investigation, the term 'urodynamic study' is usually reserved for the more complex filling and voiding pressure studies - i.e. a cystometrogram (CMG). These studies are usually combined with X-ray screening during the test and the data can be stored on video to enable playback at a later date. This latter study is referred to as a video cystometrogram (YCMG) and is the most common form of urodynamic investigation. More specialised urodynamic studies include ambulatory urodynamic studies (where the bladder is allowed to fill naturally with the patient's own urine), and upper tract studies (where the renal pelvis is filled directly via nephrostomy to investigate situations of equivocal pelvi-ureteric obstruction) '. This editorial will concentrate on situations involving video-urodynamic studies. The physiology of micturition and a urodynamic classification of dysfunction The normal bladder is required to function not only as a reservoir for urine (storage phase of micturition) but it is also required to empty in a co-ordinated and efficient manner in socially acceptable situations (voiding phase of micturition). The properties required of a normal bladder during the storage phase are the accomodation of increasing volumes of urine at a low intravesical pressure, with normal sensation, a closed bladder outlet and no involuntary bladder contractions (detrusor instability). During the voiding phase, the bladder is required to generate a co-ordinated detrusor contraction of adequate magnitude and duration to enable emptying. This should be combined with the simultaneous relaxation of the smooth and striated urinary sphincters and there should be no anatomical obstruction. Yideo-urodynamic studies are intended to evaluate all aspects of the two phases of micturition. The questions posed during the storage phase of micturition are: - is there normal or poor compliance - normal, reduced or increased sensation - a competent or incompetent bladder outlet - the presence or absence of abnormal involuntary detrusor contractions? During the voiding phase: - is there a normal, low or high voiding pressure - complete or incomplete emptying - co-ordinated or dyssynergic voiding - a normal or obstructed bladder outlet? The International Continence Society (ICS)2 has encouraged a classification of lower urinary tract dysfunction based on urodynamic investigation and this is summarised in the table. When is urodynamlc investigation indicated? Situations where urodynamic evaluation can aid in the clinical management of the patient include the investigation of incontinence and troublesome symptoms of urinary frequency, urgency and suprapubic pain. Urodynamic studies are particularly important when lower urinary tract dysfunction is associated with upper tract abnormalities such as reflux and hydronephrosis. The prime objective of the study is to reproduce the clinical situation that is being investigated and it is often necessary to tailor the technique in order to obtain this pertinent information. Although incontinence and irritative urinary symptoms are foremost on the patient's mind, the prime objective of the clinician is to preserve renal function. Other goals of management include: - the control of urinary infection - adequatae storage of urine at a low intravesical pressure - efficient emptying at reasonable voiding pressures - to provide, overall, a situation which is socially acceptable - where possible, without the need for a catheter or urinary stoma It is convenient to classify lower urinary tract dysfunction into neuropathic (secondary to a neurological condition) or non-neuropathic (where there is no overt neurological aetiology). Neurological conditions may be classified according to the level of neurological damage3. Peripheral nerve damage can occur following radical colo-rectal or gynaecological surgery and may result in an atonic bladder4·5. When conditions such as multiple sclerosis affect the suprasacral region (i.e. above the sacral miturition reflex centre), the result is often an unstable bladder and unco­ordinated and inefficient emptying6. Conditions that occur above the pontine micturition centre such as with Parkinson's disease? or following a stroke, often results in a lack of voluntary inhibition of micturition so that although co-ordinated voiding occurs, it happens without the patient being aware of it and results in incontinence. Traumatic spinal cord injuries may occur at any level 11 1 The use of urodynamic studies to help sort out bladder problems and the resultant dysfunction will depend on the level of the damage and the extent of the damage at that level8. Non-neuropathic conditions that may require urodynamic evaluation include the evaluation of female incontinence. Urodynamic studies can determine the type of incontinence (urge-, stress-, mixed or continuous incontinence) and thereby help the clinician decide the most appropriate treatment strategy. It is certainly advisable to perform a full urodynamic assessment prior to continence surgery9 and also in situations where bladder reconstruction is being considered \0. Urodynamic assessment may be indicated in certain situations of equivocal prostatic bladder outflow obstruction and can help differentiate between the high pressure/low flow scenario (where patients do well following prostate surgery), and the low pressure/low flow situation (where patients do not usually benefit from prostate surgery) 11. The management of other conditions such as the painful bladder l2 and the urge syndrome l3 may also be helped by formal urodynamic evaluation. The main indication for urodynamic evaluation in the paediatric patient is in the evaluation of the neuropathic bladder (particularly that caused by spina bifida). It is very important for the clinician to determine whether the patient has a 'hostile' bladder that may cause upper tract damage and renal impairment if left untreated and urodynamic studies form the basis for this assessment l4 . Urodynamic studies may also be helpful in children with diurnal incontinence, in children where primary empirical treatment has failed and also where there is a suspicion of severe dysfunctional voiding as evidence by residual urine, a thickened bladder wall and upper tract dilation 15. Overall, however, urodynamic evaluation in children is rarely indicated before the age of five years. Conclusion The initial evaluation of a patient with symptoms of lower urinary tract dysfunction should include a full history and examination and baseline non-invasive tests. References I. 	 Mundy AR, Stephenson TP, Wein AJ. Urodynamics: Principles, practice and application (ed) Churchill Livingston 1994. 2. 	 Abrams P, Blaivas J, Stanton S, Anderson J. Standardisation of terminology of lower urinary tract function. j-leurourol Urodynam 1988; 7:403. 3. 	 Kirby RS. Studies of the neurogenic bladder. Annals of the RCS of England 1988; 70:285-288. 4. 	 Fowler AD, Bremner DM, Moffat LEF. The incidence and consequences of damage to the parasympathetic nerve supply to the bladder after abdominoperineal resection of the rectum for carcinoma. Br J Urol 1978; 50:95-98. 5. 	 Mundy AR. An anatomical explanation for bladder dysfunction following rectal and uterine surgery. Br J Uro11982; 54:510-514. 6. 	 Philip T, Read DJ, Higson RH. The urodynamic consequences of multiple sclerosis. Br J Urol 1981; 53:672-675. 7. 	 Fitzmaurice H, Fowler CJ, Rickards D, Kirby RS, Quinn NP. Micturition disturbances in Parkinson's disease. Br J Urol 1985; 57:652-656. 8. 	 Thomas DG, Small wood R, Graham D. Urodynamic observations following spinal trauma. Br J Urol 1975; 47:161-175. It is well-known that there is a poor correlation between symptomatology and bladder dysfunction 16 and therefore in certain situations, patients may also warrant a formal urodynamic assessment. It is also well-known that treatment based on signs and symptoms alone is less effective than treatment based on urodynamic testing 1? An exact diagnosis is especially important when invasive and potentially irreversible therapy is being considered, Armed with more detailed information about the function of the lower urinary tract, the clinician should be better able to advise on specific treatment measures and also be in a position to predict their likely outcome. Table - The International Continence Society Classification Storage Phase Voiding Phase Bladder function Bladder function Detrusor activity Detrusor activity - normal - normal - overactive - underactive Bladder sensation - acontractile - normal - hypersensitive Urethral function - hyposensitive - normal - absent - obstructive Bladder capacity - normal - high -low Compliance - normal - high -low Urethral function - normal - incompetent 9. 	 Byme DJ, Stewart PAH, Gray BK. The role of urodynamics in female urinary stress incontinence. Br J Urol 1987; 59:228-229. 10. Goldwasser B, Barret DM, Webster GD, Kramer SA. Cystometric properties of ileum and right colon after bladder augmentation, substitution or replacement. J Urol 1987; 138:1007-1008. 11. 	 Abrams PH, Griffiths DJ. The assessment of prostatic obstruction from urodynamic measurements and from residual urine. Br J Urol 1979; 51: 129-134. 12. 	 Perez-Marrero R, Emerson L, Juma S. Urodynamic studies in interstitial cystitis. Urol 1987; 29:27-30. 13. 	 Stephenson TP, Mundy AR. The urge syndrome. In: Urodynamics: Principles, practice and ap,plication. (Ed) Churchill Livingston 1994. 14. 	 Weston PM, Robinson LQ, Williams S, Thomas M, Stephenson TP. Poor compliance early in filling in the neuropathic bladder. Brit J Urol 1989; 63:28-31. 15, 	 Webster GD, Koefoot RB, SheInik S. Urodynamic abnormalities in neurologically normal children with micturition dysfunction. J Uro11984; 132:74-77. 16. 	 Versi E, Cardozo L, Anand D, Cooper D. Symptom analysis for the diagnosis of genuine stress incontinence. Brit JObs Gynae 1991; 98:815-819. 17. 	 Blaivas JG. Management of bladder dysfunction in multiple sclerosis. Neurol 1980; 30: 12. The copyright of this article belongs to the Editorial Board of the Malta Medical Journal. The Malta Medical Journal’s rights in respect of this work are as defined by the Copyright Act (Chapter 415) of the Laws of Malta or as modified by any successive legislation. Users may access this full-text article and can make use of the information contained in accordance with the Copyright Act provided that the author must be properly acknowledged.  Further distribution or reproduction in any format is prohibited without the prior permission of the copyright holder. This article has been reproduced with the authorization of the editor of the Malta Medical Journal (Ref. No 000001)  

Cystometric properties of ileum and right colon after bladder augmentation, substitution or replacement.

Poor compliance early in filling in the neuropathic bladder.

Symptom analysis for the diagnosis of genuine stress incontinence. Brit JObs Gynae

The assessment of prostatic obstruction from urodynamic measurements and from residual urine.

The role of urodynamics in female urinary stress incontinence.

The urge syndrome. In: Urodynamics: Principles, practice and ap,plication.

Urodynamic studies in interstitial cystitis. Urol

The use of urodynamic studies to help sort out bladder problems

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The use of urodynamic studies to help sort out bladder problems

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