Mr. D arrived for testing stating he was unable to come with a full bladder as instructed and had urinated about 30 minutes prior to arrival. The patient was given instruction to try not to leak urine and pad testing was completed. The patient had 15 grams of urine leakage. Immediately following the pad test, uroflow/post-void residual (PVR) was completed. Voided volume was 73 ml, maximum flow rate was 7.4 ml/s, and PVR was 10 ml. Video urodynamics was completed using a 7 Fr dual lumen catheter. The study revealed a large capacity but otherwise uneventful filling phase. Stress UI was not demonstrated even with an abdominal pressure of 115 cmH20. The patient was unable to void around a 7 Fr catheter but had detrusor pressures within normal limits at 39 cmH20. The catheter was removed and the patient voided by using Valsailva. The maximum flow rate was 8.6 ml/s, and PVR was 40 ml.
An attempted flexible cystoscopy performed by the urologist revealed a pinhole urethral stricture. Mr. D tolerated urethroscopy poorly because of discomfort and was unable to tolerate any attempt at urethral dilatation. Mr. D was scheduled for cystoscopy and dilatation under anesthesia.
This case presents interesting considerations for the urodynamic nurse and for the urologist. The first question that comes to mind when reviewing this case history is the trial use of oxybutynin for stress UI. Oxybutynin is often very useful for urge incontinence but can increase retention and add to overflow and stress UT in obstructive conditions.
The issue of obstruction would be of primary concern for a post-TURP patient who develops stress UI after 6 nonsymptomatic years. If obstruction from urethral stricture or prostatic regrowth were primary considerations, then a simple cystoscopy would have revealed these in a more cost-effective manner and by a less invasive procedure for the patient.
As the urodynamic nurse, it is important to consider the patient's history. Knowledge of the probability of obstruction should guide testing. The original pad testing did reveal significant incontinence at small volumes. The uroflow showed low, intermittent flow suggestive of Valsalva voiding. Questioning the patient further on his symptoms and the use of Valsalva voiding can be revealing. With careful questioning in simple terms, this patient did verbalize the need to Valsalva to void.
The previously mentioned noninvasive findings, suggestive of obstruction, were supported by the catheterization, which revealed tightness at the proximal urethra. All these indicators combined, direct the procedures used during video urodynamics. When the inability to demonstrate leakage with high abdominal pressures was revealed, the obstruction was almost certain. The patient was unable to void around the 7 Fr urodynamic catheter even though he had adequate detrusor pressure. This led the urodynamist to evaluate voiding without the catheter. When the catheter was removed, the patient voided with low flow and Valsalva voiding. This maneuver replicated his usual voiding pattern. The urethroscopy revealed the extent of the obstruction and confirmed the urodynamic findings.
In conclusion, patient history and current symptoms need careful consideration both in determining the appropriateness of diagnostic tests and in the procedures used during the testing. Urodynamics are only as thorough as the urodynamist.
Linda M. Diller, BSN, CURN, is Urology Special Procedure Nurse, Veterans Administration Health Care System, La Jolla, CA.
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|Title Annotation:||transurethral resection of the prostate|
|Author:||Diller, Linda M.|
|Date:||Feb 1, 2000|
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