Urodinamica abc

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Urodinamica abc

  1. 1. URODINAMYCS: a prime for the beginner by GIANCARLO VIGNOLI, MD Urodynamics and Urogynecological Unit Casa “Madre Fortunata Toniolo” Bologna
  2. 2. Foreword <ul><li>Urodynamics describes a group of physiological tests that are used in clinical practice to investigate abnormalities of lower urinary tract function. Contrary to popular belief, it is not an esoteric subject of limited applicability or difficult science. In fact, the principles underlying urodynamics are simple, and the techniques entirely logical in their application </li></ul>
  3. 3. Summary <ul><li>Micturition cycle </li></ul><ul><li>History & Physical “ urodynamically – oriented” </li></ul><ul><li>Non-invasive urodynamics </li></ul><ul><li>Invasive urodinamics </li></ul><ul><li>Videourodynamics </li></ul><ul><li>Ambulatory urodynamics </li></ul><ul><li>Diagnostic software </li></ul>
  4. 4. <ul><li>Sources : </li></ul><ul><li>Blaivas J, Lower Urinary Tract Physiology and Pathophysiology,FUUS 2008 </li></ul><ul><li>Blaivas J ,Evaluation of Lower Uirnary Tract Dysfunction, FUUS 2009 </li></ul><ul><li>Hosker G , Good Urodynamic Practice,ICS 2008 </li></ul><ul><li>Kastgir J et a.Course on Urodynamics ,TTmed Urology,2010 </li></ul><ul><li>Life-Tech Introduction to Urodynamics </li></ul><ul><li>Yasuhiko Igawa,Neurogenic Bladder, ICS 2007 </li></ul><ul><li>Khalafalla AH,Urethral Pressure Profile (web slides) </li></ul>
  5. 5. Micturition cycle: filling <ul><li>As the bladder fills progressively, relaxation of the bladder (detrusor) muscle allows low pressure storage of urine, aided by inhibitory mechanisms within the spinal cord and pelvic ganglia. Concurrently, the complex system of sphincters that encircle the urethra start to contract in keeping with bladder filling in order to increase urethral resistance and maintain continence. </li></ul>
  6. 6. Micturition cycle: voiding <ul><li>Conversely, voiding is a voluntary act that is associated with a lowering of urethral resistance by sphincter relaxation followed by a coordinated contraction of the detrusor muscle which leads to complete emptying of the stored urine. </li></ul>
  7. 7. Related events <ul><li>Voluntary interruption of voiding </li></ul>
  8. 8. <ul><li>Cough </li></ul>
  9. 9. <ul><li>Strain ( Valsalva) </li></ul>
  10. 10. <ul><li>This combination of physiological and mechanical functions may be altered by various processes, and manifests in various ways, such as incontinence, detrusor muscle overactivity, voiding dysfunction, and so on. </li></ul><ul><li>Urodynamics in its purest sense is the study of the relationship between bladder pressure, volume and flow at the various stages of the micturition cycle. </li></ul>
  11. 11. No–instruments urodynamics <ul><li>It is important for the clinician to have a rudimentary understanding of the physiological processes involved and to endeavor to make a urodynamic diagnosis from the start, which is then confirmed or refuted by subsequent tests </li></ul><ul><li>By employing good basic clinical skills of detailed history-taking, physical examination and a selection of simple investigations, most problems may be diagnosed in the outpatients or office setting with a rather basic understanding of lower urinary tract physiology. </li></ul>
  12. 12. Patient clinical assessment <ul><li>History including symptom score </li></ul><ul><li>         Physical examination which includes: </li></ul><ul><li>                   - Digital rectal examination (DRE) for men </li></ul><ul><li>                   - Pelvic examination for women </li></ul><ul><li>                   - Focused neurological examination </li></ul><ul><li>         Frequency volume chart/voiding diary </li></ul><ul><li>         Urine dipstick analysis </li></ul><ul><li>         Urine microscopy and culture </li></ul><ul><li>         Post-void residual volume (bladder scan) </li></ul><ul><li>         Pad test </li></ul><ul><li>         Q-tip test </li></ul><ul><li>  </li></ul>
  13. 13. Patient Sheet Front Page <ul><li>Patient : Ref : </li></ul><ul><li>Age : </li></ul><ul><li>Main symptom : * </li></ul><ul><li>Degree of bother: * </li></ul><ul><li>Comorbidities: </li></ul><ul><li>Drugs: </li></ul><ul><li>Previous surgery : </li></ul>
  14. 14. Questionnaires * <ul><li>Incontinence Impact Questionnaire (IIQ) </li></ul><ul><li>Urogenital Distress Inventory (UDI) </li></ul><ul><li>International Prostate Symptom Score (IPSS) </li></ul>
  15. 15. Types of Bladder Diary <ul><li>Micturition time chart </li></ul><ul><li>Frequency - volume chart </li></ul><ul><li>Complete Bladder diary ( including fluids,degree of urgency ,etc.) </li></ul>
  16. 16. Electronic Bladder Diary
  17. 17. Informations derived from Bladder Diary <ul><li>It provides an objective record of symptoms (frequency, leakage episodes) and their severity </li></ul><ul><li>Maximum and average voided volumes, the “functional bladder capacity” </li></ul><ul><li>Distinguishes frequency from global polyuria (> 2.8 L urine output in 24 h) </li></ul><ul><li>Distinguishes between nocturia and nocturnal polyuria (nocturnal polyuria is > 30% of total 24-hour output occurring at night; it may reflect the presence of extraurinary tract pathology such as congestive cardiac failure, and abnormalities of antidiuretic or atrial natriuretic hormone secretion) </li></ul>
  18. 18. 1-hour Pad Test ( positive > 5 gr) <ul><li>ICS RECOMMENDATIONS: </li></ul><ul><li>1. Patient voids </li></ul><ul><li>2. Pre-weighed collecting device is put on and 1-h test begins </li></ul><ul><li>3. 0-15 min: subject drinks 500 mL of sodium-free liquid and sits/rests </li></ul><ul><li>4. 15-45 min: subject walks and climbs equivalent of one flight up and down stairs </li></ul><ul><li>5. 45-60 min: subject performs following activities:      - standing up from sitting 10 times     - coughing vigorously 10 times     - running on the spot for 1 min     - bending to pick up small objects off the floor five times     - washing hands in running water for 1 minute </li></ul><ul><li>6. At the end of the 1-h test the collecting pad is removed and reweighed </li></ul><ul><li>7. If the test is thought to be representative, the subject voids and the volume is recorded </li></ul>
  19. 19. Vaginal Examination ( Inspection )
  20. 20. Vaginal Examination ( Stress Test )
  21. 21. Q-TIP TEST
  22. 22. POP-Q Instruments
  23. 23. POP-Q iuga simplified version <ul><li>gh 3 cm </li></ul><ul><li>pb 2 cm </li></ul><ul><li>Tvl 10 cm </li></ul><ul><li>Ap 3 cm </li></ul><ul><li>Bp 3 cm </li></ul><ul><li>Source : Swift S , 2006 </li></ul>
  24. 24. POP-Q ( gh : 3 cm )
  25. 25. POP-Q ( D : 10 cm )
  26. 26. POP-Q ( Aa : 3 cm )
  27. 27. POP-Q ( Ap : 3cm )
  28. 28. BARD Interactive Guide
  29. 30. Focused Neurological Examination <ul><li>Perianal sensation </li></ul><ul><li>Anal reflex ( scratching the perineum makes the anus “wink”) </li></ul><ul><li>Anal sphincter tone & Voluntary control </li></ul>
  30. 31. Non-invasive urodynamics
  31. 32. Flowmetry
  32. 33. <ul><li>Uroflowmetry is a simple, noninvasive technique which is easily performed in the outpatient setting and is often used as a screening test for voiding problems, or a means of selecting patients who require more complex urodynamic studies </li></ul>
  33. 34. Flow Recorders <ul><li>Weight </li></ul><ul><li>Rotating Disc </li></ul>
  34. 35. Commode
  35. 36. Flow Curve Analysis
  36. 37. Qmax : Normal Ranges Males under 40 years: > 21 mL/sec                       Females under 50 years: > 25mL/sec          Males 40-60 years: > 18 mL/sec                           Females over 50 years: > 18 mL/sec Males over 60 years: > 13 mL/sec
  37. 38. Male Free Flowmetry Predictive Value <ul><li>Qmax < 10 mL/sec:     90% have bladder outflow obstruction </li></ul><ul><li>Qmax 10–14 mL/sec:   67% have bladder outflow obstruction </li></ul><ul><li>Qmax > 15 mL/sec:     30% have bladder outflow obstruction </li></ul>
  38. 39. Flow Nomograms <ul><li>Siroky ( male < 50) Bristol ( male > 50) </li></ul><ul><li>Liverpool ( women ) </li></ul>
  39. 40. Pediatric Flow Nomograms ( < 14 y.o.)
  40. 41. Post-Voiding Residual (Ultrasounds & Bladder Scan)
  41. 42. Post- Voiding Residual : Normal Ranges <ul><li>Poorly defined </li></ul><ul><li>50 ml lower threshold </li></ul><ul><li>50-100ml equivocal </li></ul><ul><li>>100ml abnormal </li></ul><ul><li>>300ml check upper tract </li></ul>
  42. 43. Clinical Samples
  43. 44. Normal Tracing
  44. 45. Bladder Outflow Obstruction
  45. 46. Urethral stricture
  46. 47. Abdominal straining or Detrusor – Sphincter dyssinergia
  47. 48. Common artefacts <ul><li>Moving back and forth </li></ul><ul><li>Squeezing glans </li></ul>
  48. 49. Invasive Urodynamics Cystometry & Pressure/Flow study
  49. 50. Clinical Preparation <ul><li>The only absolute contraindication to urodynamics is a clinical urinary tract infection ! </li></ul><ul><li>The best way to determine the presence of infection is to simply do a dipstick on the patient’s urine when they arrive and perform a uroflow </li></ul><ul><li>Patient’s with positive dips (nitrite) should be rescheduled and treated after catheterized urine is sent for analysis.   </li></ul><ul><li>There are no urodynamic emergencies! </li></ul><ul><li>When unsure of the safety of the situation, always consider rescheduling . </li></ul><ul><li>Source : Life-Tech Introduction to Urodynamics </li></ul>
  50. 51. Life-Tech Urolab
  51. 52. Examination Chair <ul><li>Patient's position (including children patients) can be gradually adjusted from lying to sitting position   </li></ul>
  52. 53. Set-up
  53. 54. Catheters <ul><li>bladder ( filling & recording) </li></ul><ul><li>rectum </li></ul>
  54. 55. Air-charged catheter ( Laborie Medical Technologies) <ul><li>Micro-air charged balloon circumferentially placed around the catheter </li></ul><ul><li>Eliminate directional artifactual sensing </li></ul><ul><li>Particularly suitable for urethral pressure measurement </li></ul><ul><li>Relatively inexpensive </li></ul>
  55. 56. External strain gauges
  56. 57. Subtraction Cystometry pdet = pves-pabd <ul><li>Calibration : pdet < 6 cm H20 </li></ul>
  57. 58. Common artefacts <ul><li>Negative rectal pressure simulates a detrusor contraction </li></ul>
  58. 59. EMG
  59. 60. Types of EMG <ul><li>Two types of information can be obtained from EMG: </li></ul><ul><li>a) a simple indication of muscle behavior </li></ul><ul><li>( the kinesiological EMG ) - the usual EMG in urodynamics </li></ul><ul><li>b) an electrical correlate of muscle pathology </li></ul><ul><li>( the neurophysiological EMG ) </li></ul>
  60. 61. Patch (surface) EMG electrodes for females and males The kinesiological EMG   <ul><li>Source : Life-Tech Introduction to Urodynamics </li></ul>
  61. 62. Placement of wire electrodes in female The neurophysiological EMG <ul><li>Source : Life-Tech Introduction to Urodynamics </li></ul>
  62. 63. Placement of wire electrodes in male The neurophysiological EMG <ul><li>Source:Life-Tech Introduction to Urodynamics </li></ul>
  63. 64. EMG-Interpretation <ul><li>Synergic activity </li></ul><ul><li>Dyssinergic or Non-relaxing activity </li></ul><ul><li>Low amplitude activity* </li></ul><ul><li>* check neurophysiological study </li></ul>
  64. 65. Types of Dyssinergic activity
  65. 66. The procedure in 10 steps <ul><li>1. Check transducers reference height: this is defined at the upper edge of the symphysis pubis, and is the level at which all external transducers must be placed for all the urodynamic pressures to have the same hydrostatic component. </li></ul><ul><li>2. Check patency of fluid lines by flushing </li></ul><ul><li>Check quality control of pressure signals: the resting values for the readings should be in a typical range and adequate subtraction should be evaluated by asking the patient to cough (there should be no more than a minor deflection, if at all, on pdet) . </li></ul><ul><li>4. Suggested filling rate : 50ml/min </li></ul><ul><li>During filling there should be continuous conversation between the examiner and the patient and every endeavor should be made to reproduce the symptoms. The patient should be instructed to tell the examiner when they first develop a sensation of bladder filling and when they have normal and strong sensations to void, as well as sensations of urgency and pain.  </li></ul><ul><li>Coughs should be repeated regularly throughout the fill to check urodynamic stress incontinence </li></ul><ul><li>7 . At 200 ml of filling , patient is asked to cough and strain and VLPP is evaluated . </li></ul><ul><li>8 . Once the bladder is full, filling is stopped and the patient is asked to void into an uroflowmeter with the catheters in situ. This allows pressure-flow readings to be taken concurrently and examines the voiding phase.  </li></ul><ul><li>9 . After voiding the patient should again be asked to cough to test that the catheters have not moved during micturition .  </li></ul><ul><li>10. Failure to show equal pressure transmission after voiding would suggest that the voiding trace cannot be accurately interpreted. </li></ul>
  66. 67. Interpretation of traces
  67. 68. Assessment of Compliance <ul><li>Bladder compliance describes the relationship between bladder volume and bladder pressure (dv /dp) and is expressed as increase in bladder volume per centimeter of water increase in bladder pressure (ml/cmH20) </li></ul><ul><li>In the normal bladder with a capacity of 400ml the change in pressure form empty to full should be less than 10 cm H20, giving a figure for normal compliance of 40 ml/cmH20 </li></ul><ul><li>Values greater than 10 cmH20 or lower than 40ml/cmH20 at bladder capacity indicate a reduced compliance </li></ul>
  68. 70. Clinical Samples
  69. 71. Urgency Urodynamic Spectrum
  70. 72. Phasic contractions - Good sphincter control OAB - dry
  71. 73. Phasic contractions - Poor sphincter control OAB - wet
  72. 74. Terminal contractions - Poor brain control
  73. 75. Sensory Urgency
  74. 76. Stress Urinary Incontinence
  75. 77. <ul><li>The role of urodynamics in stress urinary incontinence is a subject of ongoing debate. </li></ul><ul><li>NICE Guidelines does not recommend the routine use of preoperative urodynamics for women suffering with stress urinary incontinence </li></ul><ul><li>However,only 50% of women who report pure stress incontinence have pure urodynamic stress incontinence </li></ul><ul><li>There is some evidence that low urethral closure pressures may be associated with poorer outcomes. </li></ul><ul><li>There is some evidence that low amplitude DO have better outcomes after repair,while high amplitude DO do worse </li></ul><ul><li>Occult SUI is associated to POP in 15-30% of the patients.       </li></ul>
  76. 78. Urodynamic stress incontinence
  77. 79. <ul><li>the involuntary leakage of urine during increased abdominal pressure, in the absence of a detrusor contraction . </li></ul><ul><li>observed leakage </li></ul>
  78. 80. <ul><li>observed leakage </li></ul><ul><li>Urethral hypermobility </li></ul><ul><li>ISD </li></ul>
  79. 81. Valsalva leak point pressure
  80. 82. Leak Point Pressure <ul><li>Leak point information is obtained either by having the patient cough or valsalva. </li></ul><ul><li>The method that provides good leak pressure information utilizes Valsalva instead of cough. </li></ul>
  81. 84. Bladder filled at 200 ml <ul><li>Analysis </li></ul><ul><li>VLPP < 60cm H20 ISD </li></ul><ul><li>VLPP 60 to 90 cmH20 Equivocal </li></ul><ul><li>VLPP > 90 cm H20 Hypermobility </li></ul><ul><li>Source : Life-Tech Urodynamics </li></ul>
  82. 85. Mixed urinary incontinence <ul><li>cough uncontrolled voiding reflex </li></ul>
  83. 86. Female obstruction
  84. 87. <ul><li>There is a distinct lack of consensus relating to the use of urodynamic assessment in the interpretation of voiding dysfunction in women. </li></ul><ul><li>There are universally accepted nomograms for men with outflow obstruction but there remain various different urodynamic criteria for women. </li></ul><ul><li>Recent attempts have been made to simplify and clarify these, such as the nomogram proposed by Blaivas and Groutz in 2000, but standardization is still awaited. </li></ul>
  85. 88. BLAIVAS-GROUTZ NOMOGRAM
  86. 91. Male bladder outlet obstruction
  87. 92. Common artefacts <ul><li>Loss of bladder line during voiding </li></ul>
  88. 93. <ul><li>The main urodynamic findings in men with LUTS include: </li></ul><ul><li>- Bladder outflow obstruction ( usually secondary to benign prostatic obstruction) </li></ul><ul><li>- Detrusor overactivity ( primary or secondary to obstruction) </li></ul><ul><li>- Dysfunctional voiding </li></ul><ul><li>- Detrusor underactivity ( primary or secondary to dysfunctional voiding) </li></ul>
  89. 94. PRESSURE/ FLOW ANALYSIS ICS Nomograms <ul><li>BOO Index: pdetMax-2Qmax </li></ul><ul><li>20-40 equivocal </li></ul><ul><li><20 unobstructed </li></ul><ul><li>>40 obstructed </li></ul><ul><li>BC Index: pdetMax+5Qmax </li></ul><ul><li>150 strong </li></ul><ul><li>100-150 normal activity </li></ul><ul><li><100 weak </li></ul><ul><li>Abrams P, 1999 </li></ul>
  90. 95. Bladder outlet obstruction
  91. 96. <ul><li>The ICS has defined Dysfunctional voiding as an intermittent and / or fluctuating flow rate due to involuntary intermittent contractions of peri-urethral striated muscle during voiding in neurologically normal patients </li></ul>
  92. 97. Dysfunctional voiding
  93. 98. Non-invasive BOO analysis
  94. 99. Non-invasive BOO analysis <ul><li>Penile cuff test: </li></ul><ul><li>pressure interrupting flow is close to true isovolumetric pressure measured by conventional urodynamics </li></ul>
  95. 100. Penile cuff test nomogram
  96. 101. Pediatric dysfunctional voiding
  97. 102. Pseudodyssinergia in a boy with recurrent UTI
  98. 103. Neurogenic Bladder Source:YASUHIKO IGAWA, ICS 2007
  99. 105. Special Clinical Scenario: Spinal Cord Injury <ul><li>It is  IMPERATIVE  that clinicians performing studies on quadriplegics with a cervical spine injury at C-6 or above be prepared to recognize and treat  Autonomic Dysreflexia . </li></ul>
  100. 106. Symptoms of Autonomic Dysreflexia <ul><li>Rapid, increase in B/P of 20-40 mmHg or greater </li></ul><ul><li>Pounding headache </li></ul><ul><li>Heavy sweating (usually above the level of the SCI) </li></ul><ul><li>Goose bumps (usually above the level of the SCI) </li></ul><ul><li>Stuffy nose </li></ul><ul><li>Tightness in the chest </li></ul><ul><li>Palpitations </li></ul><ul><li>Dyspnea </li></ul><ul><li>Anxiety </li></ul><ul><li>Jitters </li></ul><ul><li>Blurred or spotty vision </li></ul>
  101. 107. When doing urodynamics on a patient with potential risk for autonomic dysreflexia: <ul><li>1. Monitor B/P and pulse continuously throug the procedure. </li></ul><ul><li>2 . Instill 2% xylocaine before catheterization. </li></ul><ul><li>3. Use body temperature fluids to fill the bladder. </li></ul>
  102. 108. <ul><li>4. Be prepared to: </li></ul><ul><ul><li>Empty the bladder immediately if B/P elevating or episode imminent. </li></ul></ul><ul><ul><li>Raise the patient’s head if not already sitting. </li></ul></ul><ul><ul><li>Reduce sustained systolic B/P greater than 150mmHg pharmacologically with rapid acting antihypertensive agents, such as Nifedipine, immediate release – “bite and swallow” </li></ul></ul><ul><li>5. Reverse symptomatic hypotension caused by sudden bladder decompression or meds. To do this: </li></ul><ul><ul><li>Lower head and raise legs. </li></ul></ul><ul><ul><li>Administer IV fluids and anit-hypotensives. </li></ul></ul>
  103. 109. <ul><li>6. Monitor the patients at least 2 hours after resolution of the episode. 7. Admit the patient to the hospital if there is poor response to treatment. 8. Document the episode according to recommended guidelines </li></ul><ul><li>Source : Life-Tech Introduction to Urodynamics </li></ul>
  104. 115. Videourodynamics
  105. 116. <ul><li>Videourodynamics ( VUDS ) adds a structural element to the functional study of standard urodynamics by enabling real-time visualization of the relevant anatomy with simultaneous pressure recordings, which makes it the most comprehensive urodynamic assessment possible. </li></ul><ul><li>VUDS is indicated when simultaneous anatomical information is required in addition to the functional data that a conventional urodynamic study provides . </li></ul>
  106. 117. Videourodynamics set-up <ul><li>Radiolucent toilet seat </li></ul><ul><li>Semilateral or oblique position </li></ul>
  107. 118. Neurogenic Bladder – Type 2 dyssinergia
  108. 119. Neurogenic bladder – Types 3 dyssinergia 4th degree reflux on the left
  109. 120. URETHRAL PROFILOMETRY
  110. 121. <ul><li>UPP is the recording of intraluminal pressure along the lenght of urethra </li></ul><ul><li>The study is performed during slow retraction ( 1 mm/s ) of a catheter with side holes </li></ul><ul><li>Bladder pressure should be measured simultaneously to exclude effects of an associated detrusor contraction </li></ul>
  111. 122. Set-Up
  112. 123. 2- or 3-ways catheters
  113. 124. Types of Profilometry <ul><li>Static urethral pressure profile ( at rest ) </li></ul><ul><li>Dynamic urethral pressure profile ( during cough ) </li></ul><ul><li>Micturational urethral pressure profile ( during voiding ).Rarely used </li></ul>
  114. 125. Step-by-step procedure <ul><li>Patient in supine ( sometime standing ) position </li></ul><ul><li>After voiding the catheter is inserted into the bladder </li></ul><ul><li>The residual urine is drained and recorded </li></ul><ul><li>The catheter is conncted to the recording equipment and to an infusion pump.The manometer is zeroed to the air at the level of the upper edge of the symphisis </li></ul><ul><li>Start infusion pump (2ml/min of saline at 37°) and recorder </li></ul><ul><li>Start retraction of catheter ( 1 mm/s ) </li></ul>
  115. 129. Urethral closure pressure ( ucp ) <ul><li>The effective pressure maintaining continence is not the urethral pressure,but the so-called closure pressure ( the urethral pressure minus vesical pressure ) </li></ul><ul><li>If the intravesical pressure ever exceeds the urethral pressure the possibility of leakage obviously exist </li></ul>
  116. 131. MUCP Normal Values <ul><li>Male : </li></ul><ul><li>70-120 cmH20 </li></ul><ul><li>Abrams P , Urodynamics , </li></ul><ul><li>3° edition ,2006,p 104. </li></ul><ul><li>Female: </li></ul><ul><li>The maximum urethral pressure increase from infancy to the age of 25 years. </li></ul><ul><li>90 cm H20 </li></ul><ul><li>Thereafter, the values decrease with increasing age </li></ul><ul><li>10 cm H20 by decade </li></ul><ul><li>Rud T ,Acta Obstet Gynecol Scand ,1980 </li></ul>
  117. 133. The stress urethral profile <ul><li>The concept of the “ stress” profile was introduced by Asmussen and Ulmsten in 1976 </li></ul><ul><li>If the closure pressure become negative on coughing then leakage is likely to occur. </li></ul><ul><li>Closure pressure may be derived electronically by subtracting intravesical pressure from intraurethral pressure and this may be displayed on chart recorder </li></ul><ul><li>Pressure transmission lower than 90% in the proximal one-third of the urethra indicates a defect in urethral support </li></ul>
  118. 135. Ambulatory urodynamics
  119. 136. <ul><li>Ambulatory urodynamic monitoring (AUM) refers to functional tests of the lower urinary tract predominantly utilizing natural filling of the urinary tract and reproducing the subject’s normal activity.  </li></ul><ul><li>  Ambulatory studies seek to improve the correlation between urinary symptoms and clinical findings.  </li></ul><ul><li>The indications for ambulatory urodynamic monitoring have been outlined in an ICS subcommittee report : - Lower urinary tract symptoms that conventional urodynamic fails to reproduce or explain  - Situations in which conventional urodynamics may be unsuitable - Neurogenic lower urinary tract dysfunction  - Evaluation of therapies for lower urinary tract dysfunction </li></ul>
  120. 138. Clinical sample : OAB Dry
  121. 139. Clinical sample : OAB Wet
  122. 140. The diagnostic software
  123. 141. <ul><li>The software is designed to develop a better understanding of urodynamics tracings </li></ul><ul><li>It does’nt make a “diagnosis”,something only a physician can do </li></ul><ul><li>It merely emphasizes a ”urodynamic diagnosis“according to current resources on urodynamic testing interpretation </li></ul>

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