What is Complex Urodynamics?
Complex Urodynamics is a series of diagnostic tests to evaluate the bladder’s function and efficiency. Urodynamic testing may be performed when: 1) the patient experiences a moderate to severe involuntary loss of urine; 2) other tests do not determine the cause of incontinence; 3) the physician suspects there is more than one cause of incontinence and; 4) the patient is considering surgery. Urodynamics will assess bladder filling, bladder storage, transportation and emptying/micturition of urine. The urodynamic study goal is to reproduce and identify the underlying causes of lower urinary tract dysfunction. According to the Standardization Committee of the International Continence Society, a good urodynamic study is comprised of three main elements: 1) a clear indication for and appropriate selection of relevant test measurements and procedures; 2) precise measurements with data quality control and complete documentation and; 3) accurate analysis and critical reporting of results. The different urodynamic studies are; 1) Uroflowmetry; 2) Cystometrogram; 3) Electromyography; 4) Leak Point Pressures; 5) Urethral Pressure Profiles and; 6) Pressure Flow Studies.
- Uroflowmetry is the first study done in urodynamics testing. Patients arrive for this study with a full bladder. Uroflowmetry measures the flow rate and volume at which the bladder empties and identifies a patient voiding pattern. A low peak flow rate can be a sign of a blockage or weak bladder. Uroflowmetry is most often followed with a post void residual(PVR) test. Post void residual measures the amount of urine left after the bladder is emptied. A post void residual (PVR) measurement can be obtained either by a thin, flexible catheter inserted into the bladder through the urethra or bladder ultrasound. This will complete the information required for the uroflowmetry study.
- The cystometrogram (CMG) is a test that measures how well the bladder can store and release urine. The bladder is filled with sterile water by an infusion pump with a catheter inserted into the bladder through the urethra. The sterile water infusion is controlled at a steady rate and vesical pressures (Pves) are monitored. A second catheter is placed in the rectum or vagina to measure intra-abdominal pressure (PAbd). As the bladder is filled with sterile water, bladder sensations from the patient’s first urge to urinate to the maximum tolerated bladder capacity are measured. During the study, vesical pressure (Pves) is subtracted from intra-abdominal pressure (PAbd) to obtain a measurement of true detrusor pressure (Pdet).
1. Vesical Pressure is the pressure exerted on the contents of the bladder. Vesical pressure is the sum of the intra-abdominal pressure from outside the bladder and the detrusor pressure exerted by the bladder wall musculature.
2. Intra-Abdominal Pressure is the steady state pressure within the abdominal cavity. Various factors such as coughing and sneezing can cause intra-abdominal pressure to increase drastically for short periods. Intra-abdominal pressure is also increased in patients who are morbidly obese, have chronic ascites, or are pregnant.
3. Detrusor Pressure is that component of vesical pressure created by the tension (active and passive) exerted by the bladder wall estimated by subtracting abdominal pressure from vesical pressure.
- Electromyography can enhance the cystometrogram study. Patch electrodes with the active electrodes placed in a clock-like fashion around the perineum and the ground or reference electrode placed on a convenient neutral area are normally used. The electrical activity of the pelvic floor muscles are monitored and recorded. This can provide important information in evaluating certain voiding dysfunctions such as detrusor/sphincter dyssynergia and assessing any potential neurological disorder that may be playing a role in the symptoms.
- Leak Point Pressure is a measurement taken of the bladder pressure at the point where leakage occurs. Leak point pressure tests the amount of abdominal pressure required to drive fluid across the urethral sphincter. This study is used to differentiate between genuine stress incontinence caused by bladder neck hypermobility versus that caused by intrinsic sphincter deficiency. This is accomplished by abdominal pressure on the bladder with a provocative maneuver such as Valsalva (VLPP) or cough (CLPP). Leak Point Pressure is particularly helpful in evaluating Stress Urinary Incontinence (SUI).
- Urethral Pressure Profile (UPP) can be employed to assess sphincter closure pressure and urethral competence during filling, voiding and abdominal pressure. The urethral pressure profile (UPP) will also measure the functional length of the urethra. This is done by manually or mechanically by pulling a specialized catheter through the urethra while monitoring and recording pressures. The UPP indicates the intraluminal pressure along the length of the urethra with the bladder at rest.
Pressure Flow Study is the voiding or bladder emptying phase of the urodynamic study. A pressure flow study will measure the detrusor and vesical pressure during the voiding phase. Electromyography (EMG) of the pelvic floor may also be useful during the voiding phase to measure detrusor/sphincter synergy. Once the voiding is complete, a Post Void Residual (PVR) measurement is taken.