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Urodynamics - PMR - Dr Henry Prakash

Urodynamics
PMR Refresher Course

Urodynamics - PMR - Dr Henry Prakash

  1. 1. HENRY PRAKASH CMC VELLORE
  2. 2. Mn U r M L MN In Onuf Bladder
  3. 3.  Aim  Reproduce symptoms  Study pathophysiology  Quantify appropriate measures
  4. 4.  Screening  Diagnostic
  5. 5.  Uroflowmetry  Cystometrogram  Video cystometrogram
  6. 6.  Non invasive  Inexpensive  Relative portability  Micturate into collecting funnel- direct calibration of flow measures
  7. 7.  ALPP Abdominal leak point pressure  Bladder compliance  Bladder sensations: First sensation of bladder filling (FSF) First desire to void (1st urge) Strong desire to void (severe urge) .  DESD - Detrusor –external sphincter dys-synergia  DLPP - Detrusor leak point pressure  IDC - Involuntary detrusor contraction
  8. 8.  LUTS: Lower urinary tract symptoms  Maximum cystometric capacity  OAB: Overactive bladder.Type 1 ,2,3,4  Pdet, Pves, Pabd  Q: Uroflow
  9. 9.  Studies storage and voiding  Ideally  Normal desire  Representative of normal voiding  Adequate privacy  Graph compared with patient’s micturition chart  USG - PVR
  10. 10.  Standard measured parameters  Maximal flow rate Qmax  VoidedVolume  ResidualVolume
  11. 11.
  12. 12.  BOO - Bladder Outlet Obsturction with Qmax cut-off 10 ml/sec to 15 ml/sec  Sensitivity : 39 to 80%  Specificity: 94 to 61% Review of lit, Jour Urology, July 2006 , 29-35
  13. 13.  Pitfalls: Doesn’t recognize BOO Vs poor detrusor Normal flow pattern if overactive detrusor + BOO Pressure flowmetry remains GOLD STD
  14. 14.  Bladder pressureVs Bladder volume  Bladder filled with fluid- water/saline/gas- at fixed infusion rate: 20-50 cc  Pressure measured with catheter placed in bladder
  15. 15.  Vesical Pr = Detrusor pr + Abd pr  Detrusor pr =Vesical Pr - Abd pr  Abdominal pressure measured by catheter in rectum  Sensation/desire to void noted  Capacity 300-600 ml
  16. 16.  1st sensation about 50% of capacity  Normal people can suppress detrusor contractions (>15 cm H2O)  Normally, bladder pressure doesn’t significantly rise till micturition: GOOD COMPLIANCE
  17. 17.  Look for  Pressure variation  Bladder sensation/urgency  Leak  Voluntary micturition effort ALWAYS, Correlate CLINICAL PICTURE + data
  18. 18.  Spinal shock (up to 6 months): areflexic  Suprasacral (usually injury above L1 vertebra)  Neurogenic Detrusor Overactivity + DSD  Sacral/Cauda equina (usually injury below L2 vertebra)  usually areflexic
  19. 19. NEUROGENIC DETRUSOR OVERACTIVITY Voided with abdominal pressure
  20. 20.  “urgency, with or without urge incontinence, usually with frequency and nocturia if there is no proven infection or other etiology.”  symptom complex caused by one or more of the following detrusor over activity, sensory urgency, and low bladder compliance.  urinary tract infection,  urethral obstruction, pelvic organ prolapse, neurogenic bladder, sphincteric  incontinence, urethral diverticulum, bladder stones/foreign body,  Bbladder cancer
  21. 21. Idiopathic DO Neurogenic DO Non neurogenic DO SUPRA SPINAL LESIONS Infection Stroke,PD,MS,Tumor,TBI,Hyd.Cep, BOO Prostatic,Urethral,stricture,UD, Prolpase SUPRA SACRAL SPINAL LESIONS Tumor,Stones,Age SCI,MS,TM,Tumor,MyeloDisp Foreign Body
  22. 22.  TERMINAL –DO  single involuntary detrusor contraction occurring at Cystometric capacity, which cannot be suppressed, and results in incontinence usually resulting in bladder emptying  PHASIC –DO  Characteristic waveform, and may or may not lead to urinary incontinence
  23. 23. UNSTABLE DETRUSOR- POOR COMPLIANCE
  24. 24.  Skin–CNS–bladder reflex  Somatic motor axons can innervate bladder parasympathetic ganglion cells and thereby transfer somatic reflex activity to the bladder smooth muscle
  25. 25.  In true DSD, increased EMG activity correlates with an ascending portion of the detrusor contraction curve  Dysfunction voiding, EMG increase is random  Sympathetic system controls the bladder neck and proximal urethra from theT10 to L2 spinal cord segments  A spinal cord lesion aboveT10 removes supraspinal inhibitory control of the sympathetic vesicourethral neurons, resulting in bladder neck functional obstruction (smooth muscle dyssynergia)
  26. 26.  Goal:  Adequate emptying  Social continence  Acceptable detrusor pressures < 40 cm H2O 2009 International ContinenceSociety guidelines.
  27. 27.  Step 1: GeneralAssessment  Demographic data  Family support  Cognitive status  Hand functions/ level of independence ↓ APPRORIATE Bladder emptying strategy Neurogenic bladder: management guidelines
  28. 28.  Step 2: Self/refex voiding (suprasacral lesions)  Goal: PVR < 100 or < 1/3 of prevoid volume Max det pressure < 40 cm H2O  Medications prn ▪ Anticholinergics low dose (Oxybutynin,Tolterodine) ▪ If leaks / high detusor pressure > 40 cm H2O ▪ Alpha1a antagonists (Tamsulosin) ▪ Poor initiation/flow- bladder neck symptoms
  29. 29. Step 3:  If self/reflex void not possible/ not safe:  CIC  SPC  IDC
  30. 30.  CIC if  Good hand functions/ trunk balance/ cognition  SPC if  Poor hand functions, urethral injury/stricture  IDC if  Hydronephrosis, gen.condition poor, co-morbidities
  31. 31.  Supportive ▪ Diapers ▪ IDC/Condom  Surgical ▪ Urinary Diversion ▪ Bladder Augmentation ▪ Intravesical / external sphincter Botox Urethral suspension
  32. 32.  Non-neurogenic voiding dysfunctions- Mx: ▪ Behavior therapy ▪ Timed voiding ▪ Pharmacology-w dose

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