interpretation of urodynamics requires basic understanding of physiology of LUT and pathophysiology of various LUT dysfunctions. The next step is to learn how to pen down the interpretation with full understanding of the findings (or any limitations came across during the study). before reporting, one must know the urodynamic questions for which answers are sought (e.g. for a man, in whom urodynamics is ordered for quantifying bladder outlet obstruction, doing a stress study looking for stress incontinence is irrelavent. Similarly, for a woman whose UDS is ordered for stress incontinence, missing out a stress study makes the whole exercise irrelevant. And so on..). One should start with mentioning the indication for UDS, the specifications of the catheters, type and temperature of filling fluid, position of patient during filling and voiding, filling rate, etc. Filling phase description should including sensations, overactivity, capacity, compliance, leak point pressures (abdominal for stress and detrusor for poor compliant bladder), EMG cough reflex, guarding reflex (if done), urethral pressure profile MUCP and length (if done) Voiding phase description to include hesitancy, PdetQmax, Qmax, type of flow, pattern of detrusor contraction, PVR, interpretation of pressure flow curves (particularly in men) - e.g. BOOI, DCI, BVE, EMG - relaxation / increased activity (if done), dynamic UPP - level of obstruction, max fall in MUCP (if done) Interpreting as "neurogenic bladder" is mostly irrelevant in reporting UDS since UDS is for functional status and NOT Neurological status.

1. REPORTING URODYNAMICS
​Dr Mayank Mohan Agarwal
​MS, MRCS(Ed), ​DNB, MCh (PGI, Chd)
​VMMF and IAUA Fellowships Uro-Oncology, Pelvic Floor Reconstruction
(MSKCC, NY; UCLA, LA; WFUBMC, NC)​
Associate Director
Urology and Kidney transplant surgery
Medanta Awadh Hospital
Lucknow

2. INTRODUCTION
• Findings in filling phase with physiological correlates
• Findings in voiding phase with physiological correlates
• Reporting pattern for multichannel urodynamics

3. FILLING PHASE
• INTRINSIC PROPERTIES – elastic / viscoelastic
• AUTONOMIC NERVOUS CONTROL
• PARASYMPATHETIC α1
• SYMPATHETIC β3
• SOMATIC NERVOUS CONTROL Aδ

4. FILLING PHASE
• INTRINSIC PROPERTIES
• AUTONOMIC NERVOUS CONTROL
• PARASYMPATHETIC
• SYMPATHETIC
• SOMATIC NERVOUS CONTROL
+ SY
+ SO
- PSY
+ -
BLADDER ↔ URETHRA REFLEXES

5. VOIDING PHASE
- SY
- SO
+ PSY
- +
BLADDER ↔ URETHRA REFLEXES

6. Uroflometry

7. Report
• Flow rates –
• Q max
• Q ave
• VV
• PVR
• Graph interpretation

8. Normalcy interpretation : Nomogram
• INDIAN NORMAL FLOWS (WOMEN) RESPECTIVE TO LIVERPOOL
NOMOGRAM (RED LINE)
• THERE WAS CLEARLY A NEED FOR SEPARATE NOMOGRAM FOR
INDIAN POPULATION

9. Normalcy interpretation :Nomogram
• INDIAN NOMOGRAM (PGIMER NOMOGRAMS)

10. Normalcy interpretation : FLOW VOLUME
INDEX (VQI)
• VQI – the BMI of uroflo
• VQI = Q / sqrtV
Agarwal et al. Neurourol Urodynam 2013

11. Cystometry - setup
• Fill rate
• Implication – physiological vs supra-physiological
(~10% of FBC on FVC or Weight/4)
• Position of patient
• Sitting / standing / squatting
• Size of catheters
• The smaller the better for bladder (dual lumen vs 2 IFT)
• Type of transducers – water / air-charged / micro-tip
• Results may not be comparable – most standardization on water
transducers
acceptable
Rosier et al. Neurourol Urodynam 2016

12. Cystometry - sensations
• Initial resting pressure
pves and the pabd pressure at the beginning of the cystometry.
• First sensation of filling (FSF)
moment when you perceive that your bladder is not empty anymore
• First desire to void (FDV)
when you have the sensation that normally tells you to go to the toilet, without any
hurry, at the next convenient moment
• Strong desire to void” (SDV)
without any pain or any fear of losing urine, will not postpone the voiding; you will
visit the nearest restroom also, for example, while shopping
• Urgency – for leak / pain
Rosier et al. Neurourol Urodynam 2016

13. Cystometry - sensations
• Initial resting pressure
pves and the pabd pressure at the beginning of the cystometry.
• First sensation of filling (FSF)
moment when you perceive that your bladder is not empty anymore
• First desire to void (FDV)
when you have the sensation that normally tells you to go to the toilet, without any
hurry, at the next convenient moment
• Strong desire to void” (SDV)
without any pain or any fear of losing urine, will not postpone the voiding; you will
visit the nearest restroom also, for example, while shopping
• Urgency – for leak / pain
SENSATIONS (FSF)
0-------100---------200---------
CAPACITY
0-------200---------600---------
COMPLIANCE
0---------10---------20----------50---------
HYPER HYPONORMAL
LOW HIGHNORMAL
V. LOW NORMALLOW HIGH

14. Cystometry
• Bladder –
 Over-activity
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

15. Cystometry
• Bladder –
 Over-activity
 Compliance
∆V/∆P
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

16. Cystometry
• Bladder –
 Over-activity
 Compliance
∆V/∆P
In case of reduced compliance – mention flow was
stopped for __min and ___drop of pressure was
observed / not observed
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

17. Cystometry
• Bladder –
 Over-activity
 Compliance
∆V/∆P
• Urethra – ♀ ♂
 Resting profile length 30mm 40-50mm
 MUCP 40-100 40-120cmH2O
Abrams P. Urodynamics 2006

18. Cystometry
• Bladder –
 Over-activity
 Compliance
∆V/∆P
• Urethra –
 Resting profile
 MUCP
• EMG –
 Guarding reflex
URETHRA
BLADDER
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

19. Cystometry
• Bladder –
 Over-activity
 Compliance
∆V/∆P
• Urethra –
 Resting profile
 MUCP
• EMG –
 Guarding reflex
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

20. Cystometry – leak point pressure
• No standard method – report as it was done
• Abdominal LPP (Urodynamic stress test) – Pves / Pabd from ZERO
• The provocation method (cough/Valsalva)
• Bladder Volume
• Detrusor LPP – Pdet at leak
• DO associated leak
• Cough associated detrusor overactivity
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

21. Cystometry – leak point pressure
• No standard method – report as it was done
• Abdominal LPP (Urodynamic stress test)
• The provocation method (cough/Valsalva)
• Bladder Volume
• Detrusor LPP
• Detrusor overactivity (DO)
• DO associated leak
• Cough associated detrusor overactivity
ALPP
0-------60------------90---------
LOW HIGHborderline
DLPP
0---------40---------
SAFE UNSAFE

22. ALPP
DLPP

23. Pressure-flow study: BNO
-
-
+
- +
+
++
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

24. BNO/BPO
• Bladder –
 Pdet
 Qmax
 PVR
 Bell-shaped curve
Pdetmax 72
PdetQmax 62
Qmax 8
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014

25. BNO/BPO
• Bladder –
 Pdet
 Qmax
 PVR
 Bell shaped curve
• Urethra –
 Pressure gradient
 Starting point
Abrams P. Urodynamics 2006; Agarwal MM. Manual of urodynamics. 2014, Jain et al. Urology 2014

26. • Bladder –
 Pdet
 Qmax
 PVR
• Urethra –
 Pressure gradient
 Starting point
• EMG –
 Relaxation
Batavia et al. J Urol 2011

27. • Bladder –
 Pdet
 Qmax
 PVR
• Urethra –
 Pressure gradient
 Starting point
• EMG –
 Relaxation
• Pressure-flow relations –
Agarwal MM. Manual of urodynamics. 2014

28. Pressure-flow study: EUSD with DUA
-
-
+
- +
-
+ -

29. EUSD
• Plateau pattern
• Flow starts at Pdetmax
• PdetQmax ≈ Pdetmax
Agarwal et al. Ind J Urol 2016

30. EUSD
• Plateau pattern
• Flow starts at Pdexmax
• PdetQmax ≈ Pdetmax
Agarwal et al. Ind J Urol 2016

31. EUSD
• Plateau pattern
• Flow starts at Pdexmax
• PdetQmax ≈ Pdetmax
• Pura gradient at EUS
Jain et al. Urology 2014

32. EUSD
• Plateau pattern
• Flow starts at Pdexmax
• PdetQmax ≈ Pdetmax
• Pura gradient at EUS
• EMG –
• Relaxation with intermittent spikes
Batavia et al. J Urol 2011

33. EUSD
• Plateau pattern
• Flow starts at Pdexmax
• PdetQmax ≈ Pdetmax
• Pura gradient at EUS
• EMG –
• Increased activity
Batavia et al. J Urol 2011

34. Pressure-flow study
• Position of patient
• pressure-flow analysis is only validated for voluntarily initiated micturitions
and not for incontinence
Rosier et al. Neurourol Urodynam 2016

35. Pressure-flow study
• Position of patient
• pressure-flow analysis is only validated for voluntarily initiated micturitions
and not for incontinence
• Comment on type of pressure-flow relation -
Normal voiding function: flow rate (and pressure-rise) are within normal
limits, begin more or less directly after permission to void and ends with an
empty bladder.
Rosier et al. Neurourol Urodynam 2016

36. Pressure-flow study
• Position of patient
• pressure-flow analysis is only validated for voluntarily initiated micturitions
and not for incontinence
• Comment on type of pressure-flow relation -
Bladder Outflow Obstruction (BOO): ‘high pressure – low flow’ type
relation, with / without hesitancy, with / without PVR [needs help from plots,
formulae, clinical correlation]
Rosier et al. Neurourol Urodynam 2016

37. Pressure-flow study
• Position of patient
• pressure-flow analysis is only validated for voluntarily initiated micturitions
and not for incontinence
• Comment on type of pressure-flow relation
Detrusor underactivity (DUA): ‘low pressure – low flow’ relation,
unsustained contraction or fading contraction with / without elevated PVR
[needs help from plots, formulae, clinical correlation]
Rosier et al. Neurourol Urodynam 2016

38. Pressure-flow study
• Position of patient
• pressure-flow analysis is only validated for voluntarily initiated micturitions
and not for incontinence
• Comment on type of pressure-flow relation
“Situational inability to void” / “Situational inability to void as usual”
when in the opinion of the person performing the test, in communication with the patient, the
attempted voiding has been not representative.
Rosier et al. Neurourol Urodynam 2016

39. CONCLUSION

40. THANK YOU