Voiding dysfunction in female final presentation

VOIDING DYSFUNCTION IN WOMEN
Dr Mayank Mohan Agarwal
MBBS, MS, MRCS(Ed), DNB, MCh (PGIMER, Chandigarh)
VMMF and IAUA Fellowships Uro-Oncology, Pelvic Floor Reconstruction
(MSKCC, NY; UCLA, LA; WFUBMC, NC)
Ex-Associate Professor of Urology (PGIMER, Chandigarh)
Consultant and Head of Urology
(Aster) Dr. Ramesh Cardiac and Multispecialty Hospitals Pvt. Ltd.
Guntur (AP), India

INTRODUCTION
• PHYSIOLOGY OF LOWER URINARY TRACT
• THE DYSFUNCTIONAL VOIDING / BBD
• WHAT TO LOOK FOR IN URODYNAMICS
• MANAGEMENT OUTLINE
• CONCLUSION

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

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

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

VOIDING DYSFUNCTION
ANATOMIC FUNCTIONAL NEUROGENIC
STRICTURE
POST-SURGICAL
PROLAPSE
BLADDER NECK OBSTRUCTION
PELVIC FLOOR DYSFUNCTION
FOWLER’S SYNDROME
Meier K, Padmanabhan P. Curr Opin Urol 2016; Kuo HC. Urology 2005.
1
23
4

KEY QUESTIONS TO BE ANSWERED
• How is bladder storage function?
• Is there an obstruction – how much? Where?
• Is there an underactivity
• Both?

Urodynamic perspective
• Bladder diary
• Free uroflowmetry ± EMG
• Cystometry + pressure-flow study
• Urethral pressure profilometry
• Micturating cystourethrography
• Video-urodynamics

Uroflowmetry ± EMG
• Ideal location – within toilet
• Ideal – “comfortably full bladder”
Never ask to hold “too much” or “hurry up”
• Always in “most preferred” voiding position
• If straining pattern (+),
ask to repeat without straining, if possible
• Always check PVR by USG

Interpretation
• Flow rates – Qmax
• Qave – particularly in intermittent flow
Agarwal et al. Neurourol & urodynam 2013, Agarwal MM. Manual of Urodynamics 2014
Qmax 11ml/s
Qave 2.9 ml/s

Interpretation
• Flow rates – Qmax
• Qave – particularly in intermittent flow
• Q α V2
• Voided volume
• Post-void residue
• Volume-normalized flow-rate index (VQI) ≡ BMI
VQI = Q/√(VV+PVR)
Agarwal et al. Neurourol & urodynam 2013

Flow-rates Indian reference values
0
5
10
15
20
25
30
35
adult male boy 5-10 boy 11-15 adult female girl 5-10 girl 11-15
Flow-rate comparison
Qmax Qave VV
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
adult male boy 5-10 boy 11-15 adult female girl 5-10 girl 11-15
VQI comparison
VQImax VQave
Agarwal et al. Neurourol & urodynam 2013, Barapatre et al. Neurourol & urodynam 2009, Gupta et al. J urol 2013
MALES FEMALES MALES FEMALES

Multichannel urodynamics
Cystometry / pressure-flow study / urethral pressure profilometry
• Not a stand-alone investigation – clinical feedback essential
• It is imperative to have bladder diary and results of free uroflowmetry with
post-void residual urine, available
• The interpretation best done in real-time
“NURSE, RUSH THIS PATIENT TO THE MATERNITY
WARD! SHE IS ABOUT TO DELIVER A BABY!”

Multichannel urodynamics
Cystometry / pressure-flow study / urethral pressure profilometry
• Not a stand-alone investigation – clinical feedback essential
• It is imperative to have bladder diary and results of free uroflowmetry with
post-void residual urine, available
• The interpretation best done in real-time
• Interpretation format –
Filling phase Voiding phase
Bladder Sensations
Capacity
Compliance
DO, LPP
Pdet – max, @Qmax,
pattern
Qmax
AG
DAMPF
Urethra Length
MUCP
Pressure-gradient
location of gradient
EMG Guarding reflex
cough reflex
Relaxation pattern

LUTD : What are we looking for in filling phase
+
+
-
+ -
+/- +/-
+/-

Filling phase
• Bladder –
 Over-activity

Filling phase
• Bladder –
 Over-activity
 Compliance
∆V/∆P

Filling phase
• Bladder –
 Over-activity
 Compliance
• Urethra –
 Resting profile
 MUCP

Filling phase
• Bladder –
 Over-activity
 Compliance
• Urethra –
 Resting profile
 MUCP
• EMG –
 Guarding reflex

Meier K, Padmanabhan P. Curr Opin Urol 2016

LUTD : What are we looking for in voiding phase
• BN Dysfunction
-
-
+
- +
+
++

BNO
• Bladder –
 Pdet
 Qmax
 PVR
 Bell-shaped curve
Pdetmax 72
PdetQmax 62
Qmax 8

BNO
• Bladder –
 Pdet
 Qmax
 PVR
 Bell shaped curve
• Urethra –
 Pressure gradient
 Starting point
Jain et al. Urology 2014

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

• Bladder –
 Pdet
 Qmax
 PVR
• Urethra –
 Starting point
• EMG –
 Relaxation
• Nomogram –
 Blaivas

LUTD : What are we looking for in voiding phase
• EUS Dysfunction
-
-
+
- +
+/-
+ -

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

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

EUSD
• Plateau pattern
• Pura gradient at EUS
Jain et al. Urology 2014

EUSD
• Plateau pattern
• EMG –
• Relaxation with intermittent spikes

EUSD
• Plateau pattern
• EMG –
• Non-Relaxation

EUSD
• Plateau pattern
• EMG –
• Increased activity

Video-urodynamics / MCUG
• Anatomical correlation with functional findings
• EUSD

• Bladder neck

• No BOO

• Additional co-diagnosis
Agarwal MM. Manual of Urodynamics 2014

• Additional co-diagnosis
• If done separately –
 Cost effective
 Catheter-less – less artefacts
 ? Difficult co-interpretation
Abrams P. Urodynamics 2006.

CONSERVATIVE MEASURES
STANDARD MEASURES –
1. Education is the key to success
2. Behavioral modification –
• Fluid and diet
• Timed voiding
• Treatment of constipation
SPECIFIC MEASURES –
1. Pelvic floor muscle exercises
2. Biofeedback
3. pharmacotherapy
4. Interventions
• CIC
• Botox
• Neuromodulation
Registration of
symptoms and
behaviors
Positive
reinforcement
and support

Behavioral Modification
• Eat and drink well – high fiber, adequate fluids
• Avoid caffeinated beverages
• Maintain hygiene
• Void timely
• Spend enough time
Santos et al. Can Asso Urol J 2017

• Eat and drink well – high fiber, adequate fluids
• Avoid caffeinated beverages
• Maintain hygiene
• Void timely (typically every 2 hours or depending on bladder diary)
• Spend enough time
• Good posture for toilet –
“SQUATTING TYPE”

Treatment of constipation –
• Manual evacuation
• Polyethylene glycol 3350 1.5g/kg stat  0.6-1.0g/kg/d
• Sodium picosulfate
• Enema
• Mineral oil

Physical therapy
• Pelvic floor exercises
• Relaxation
• Urge inhibition

Physical therapy
• Relaxation
• Urge inhibition
• Step I – IDENTIFY THE MUSCLES TO EXERCISE
• By verbal explanation –
“like stop urine stream”
“like stopping gas”

Physical therapy
• Relaxation
• Urge inhibition
• By physical examination –
DRE
PV
perianal examination

Physical therapy
• Relaxation
• Urge inhibition
• By dedicated Biofeedback –
if above two don’t work or
while doing the UDS
Biofeedback training
Ed used to be an incurable optimist
But now ne is cured

Biofeedback – done during uroflo with EMG

Biofeedback – done during UPP with EMG

Biofeedback – urge inhibition during UDS

STEP 2 - Exercise schedule
• For pelvic floor relaxation –
Squeeze 3-10 sec Relax 20-30 sec
• For urge inhibition –
Squeeze 5-10 times Relax for a sec
• For strengthening –
Squeeze 2-10 sec Relax for 1:1
45-60 SQUEEZES / D TO START WITH
± BIOFEEDBACK SESSIONS 1-2/WEEK FOR 45-60MIN 6-12 WEEKS

Outlet relaxation: PHARMACOTHERAPY
Alpha blockers
• Tizanidine
• Baclofen

Outlet relaxation
Alpha blockers
• Terazosin – α1 (-)
• Tamsulosin – α1a (-)
Skeletal muscle relaxants
• Baclofen – GABA-B (+) @ CNS
• Tizanidine – α2(+) @ CNS
• Effort should be made to diagnose level of non-relaxation
• EUD non-relaxation more common than BN obstruction in women
• α1 receptors possibly present in EUS too – combination may be acceptable
option
• High quality evidence is lacking – so treatment is empirical
Athanasopoulos et al. IUJ 2009; Constantini et al. Urol int 2009; Cisternino et al. Urol Int 2006; Xu et al. BJUI 2007; Chen et
al. J obs gyn res 2016;

Outlet relaxation: SURGERY
BNI
• BOTOX
• SNM

Outlet relaxation: SURGERY
• BNO: Bladder neck incision /
resection
• 5-7 or 10-2 or 3-6-9-12 O’clock
• Excellent functional results
• SUI
• VVF
• EUSD: Botox into sphincter
• SNM: S3
• Pain
• Reoperation
• Loss of efficacy
• High quality evidence is lacking
Zhang et al. Urology 2014; Jin et al. Urology 2012
Phelan et al. J urol 2001; Kuo HC. Urology 2003; Kerrebroek et al.
J urol 2007; Sutherland Neurourol Urodynam 2006

Conclusion
• Urodynamics has a great role to play in diagnosis of voiding dysfunction.
• ‘Reading between the lines’ beyond convention is required
• Real-time interpretation is most preferred
• Biofeedback can be taught during the urodynamic study as well
• High quality evidence is lacking, therefore balance of art and science
of treatment

-HAND HYGIENE-
-PLACE HYGIENE-
-LESS ANTIBIOTICS-

Compiled experience 2014-2017
• 33 adults with EUSD / double obstruction (median 46.6, IQR 39-53)
• Duration of symptoms (48m, 15-96)
• LUTS – all
• Constipation – 9, fecal urgency – 1
• Pelvic &/or low back pain – 16
• Improvement with alpha blocker – 8 (4 mild)
• Improvement with addition of tizanidine – 13 (3 mild)

Voiding dysfunction in female final presentation

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