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Urodynamics: focus on the geriatric patient.

Lower urinary tract symptoms (LUTS) in older adults are very common. These symptoms include urinary frequency, urgency, incontinence, dysuria, nocturia, and retention. The pathophysiology of these issues varies as well. Etiology can be obstructive, non-obstructive, or a combination. These symptoms can have a detrimental impact on quality of life. According to the EPIC study, the largest population-based survey to assess LUTS in five countries, storage symptoms, including any type of incontinence, reported a prevalence of 10.4% in men over age 60 years and 19.3% of women over 60 years. In addition, voiding symptoms in general were noted in 37.2% of men and 24.6% of women over 60 years of age (Irwin et al., 2006). Mahdy and Ghonium (2014) reported that 15% to 50% of older adults, as well as up to 40% of nursing home residents, are affected by urinary incontinence. The economic burden of overactive bladder (OAB) along with urge urinary incontinence in 2007 was $65.9 billion, with projected costs of $76.2 billion in 2015 and $82.6 billion in 2020 (Coyne et al., 2014). This represents a staggering economic burden in the United States.

As adults age, so do their bladders. Most bladders develop a decreased capacity, decreased compliance, and weaker contractility as they age. Conditions such as Parkinson's disease, dementia, cerebral vascular accident, spinal stenosis, degeneration of the spine, and other neurological diseases, which are more prevalent in the geriatric population, can lend to a more complicated urological diagnosis (Berni & Cummings, 2004). Nocturnal output also tends to increase with age (Elbadawi, Hailemariam, Yalla, & Resnick, 1997). All of these changes can result in mixed problems that can present in different ways, resulting in a challenge for the older adult patient to articulate.

There are also gender differences. In women, there are more persistent urgency symptoms along with decreased detrusor contractility (Shin, On, & Kim, 2015). In older women, peri-genital estrogen becomes depleted. Estrogen receptors in the vagina, pelvic floor, bladder, and urethra are no longer being nourished by estrogen. Consequently, vaginal tissues become dry and atrophic, pelvic floor muscles weaken, and bladder urgency can become a problem (Robinson & Cardozo, 2011). In men, prostates eventually enlarge (Glazener et al., 2011), which can subsequently cause obstruction, irritative symptoms, and difficulty voiding and urinary retention. A large multinational study revealed that 45.3% of men aged 70 to 80 years have moderate to severe LUTS (Rosen et al., 2003). The prevalence of LUTS increases as men age, including both storage and voiding symptoms (Kuo, 2007).

The diagnostic evaluation of all urologic diseases should begin with an extensive medical history that includes a current medication list and a physical examination. The physical examination should include a pelvic examination for females and prostate examination for males, abdominal examination, urinalysis, urine culture (if appropriate), and measurement of post-void residual (PVR), along with a uroflow (Rosier et al., 2016). Voiding diaries can be one of the most useful assessment tools, especially with patients who have a difficult time articulating their symptoms. A three-day record that includes voiding times, voided volumes, leakage episodes, and amount and type of fluid intake would be ideal (Bright, Cotterill, Drake, & Abrams, 2012; Jimenez-Cidre et al., 2015). Unfortunately, compliance with this type of request can be a challenge for many patients, particularly those who might be confronted with memory, vision, dexterity, or mobility difficulties. Additional assessment tools could include questionnaires and various other tests (see Table 1). In some cases, diagnosis and initial treatment plans can be determined after computation of these data, but in cases where there are still questions about specific urinary tract functions that need to be answered, urodynamics should be considered as a next step (Al-Zahrani & Gajewski, 2016).

Evaluation

For normal storage and emptying to occur, the bladder and bladder outlet must function in a proper and coordinated fashion. According to Wein (1981), all lower urinary tract dysfunction can be classified under the following rubrics (see Table 2):

* Is there a "failure to store" (incontinence), a "failure to empty" (retention), or a combination of both?

* Is there a problem due to a dysfunction of the "bladder," a dysfunction of the "outlet" (urethra), or a combination of both?

See Figure 1 for examples of "failure to store" and "failure to empty" as they relate to the bladder and outlet.

"Urodynamics" is a collection of tests where determining "failure to store" or "failure to empty" becomes the goal. This collection of tests measures bladder, urethral, and pelvic floor muscle function in an attempt to diagnose disorders of the lower urinary tract (Chapple, MacDiarmid, & Patel, 2009). The tests can be as simple as non-invasive uroflow testing with PVR measurements or more complex, including; multichannel filling cystometry, leak point pressure testing, urethral pressure testing, pressure flow studies, electromyography, and fluoroscopy.

A skilled clinician who understands the complexities of the aging bladder and accompanying patient symptoms should perform urodynamics in the elderly. Objective data are only part of the interpretation. Integration of comorbidities along with a clear understanding of how the patient's symptoms, history, and physical findings relate to the urodynamic findings are key components of proper diagnosis and treatment. Explaining the procedure to the patient is an important element in patient cooperation, which is necessary for the best possible outcomes. Assessment of the mental and physical readiness of the pa tient's ability to perform tasks required of him or her during testing is also essential for meaningful results.

Indications for Urodynamic Testing

Indications for urodynamic testing in the geriatric population might include, but are not limited to the following.

History Is Complicated Or Unclear

* An 82-year-old female patient presents with mixed urinary incontinence symptoms, recently treated for UTI, has two documented PVR volumes that exceed 200 ml, and has diabetes mellitus. The patient is ambulatory and able to follow directions.

* An 80-year-old female patient with history of previous pelvic floor surgery presents with urinary leakage that she is unable to describe as stress or urge. She denies noticing leakage with cough, sneeze, or exertion. She does not complain of urgency. She does not awaken to void during the night but often wakes up wet. She soaks six large pads per day. The patient is ambulatory and able to follow directions.

Questions to be answered by urodynamic testing:

* Is there failure to store: Due to bladder (detrusor overactivity) or outlet (stress incontinence)

* Is there failure empty: Due to bladder (underactive/hypotonic) or outlet (compromised urethra).

Physical Examination Or Preliminary Findings Do Not Match History Or the Patient's Symptoms

* A 75-year-old active and healthy female patient, who denies bladder leakage, presents with Grade 4 uterine prolapse and desires a hysterectomy. Her PVR is 100 ml, and there is suspected urethral compromise.

Questions to be answered by urodynamic testing:

* Is there failure to store: Due to outlet (occult stress incontinence-prolapse will need tobe reduced during the urodynamic stress test)?

* Is there failure empty: Due to outlet (urethral obstruction due to unreduced cystocele and urethral kink or is the bladder underactive)?

Neurological Involvement Is Suspected

* An 80-year-old male patient presents with retention, nocturia, frequency, urgency, and rare urge incontinence. Benign hypertrophic prostate (BPH) is suspected, but the patient also has history of spinal stenosis and transient ischemic attacks (TIAs). The patient is ambulatory with left lower extremity (LLE) weakness and is mentally intact.

Questions to be answered by urodynamic testing:

* Is there failure to store: Due to bladder (detrusor overactivity)?

* Is there failure empty: Due to outlet (BPH with obstruction high pressure slow flow) or bladder (underactive/hypotonic)?

Upper Urinary Tract Compromise Is Suspected (Also Neurological Involvement)

* A 63-year-old male patient with urinary retention, history of multiple sclerosis (MS), and recent development of hydronephrosis. The patient is mostly confined to a bed and wheelchair. His nursing staff catheterize him four times daily, and he is dry in between catheterizations.

Questions to be answered by urodynamic testing:

* Is there failure to store: Due to bladder (poor compliance with suspected high storage pressure and possible reflux)?

* Is there failure to empty: Due to outlet (DSD)?

In patients with known neurogenic bladders, storage pressures greater than 40 cm [H.sub.2]O are known to be associated with upper urinary tract damage, and usually associated with poor compliance and outlet obstruction (McGuire, Woodside, Borden, & Weiss, 1981). Urodynamics can be helpful in this situation to determine safe bladder volumes.

Urodynamic Data Are Needed To Evaluate the Effectiveness Of an Intervention

* An 83-year-old male patient with known obstructive BPH and solitary kidney has been treated with finasteride (Proscar[R]) and tamsulosin (Flomax[R]) for the past nine months. His symptoms have significantly improved, although his PVR remains at 250 ml. The patient has not developed any recent urinary tract infection (UTI), but creatinine levels are slightly elevated. The patient is ambulatory and mentally intact.

Questions to be answered by urodynamic testing:

* Is there failure to empty: Due to outlet (BPH with obstruction-high pressure slow flow; are voiding pressures safe for kidney preservation)?

* Is there failure to empty: Rule out due to bladder (underactive/hypotonic)?

Urodynamics is performed with an attempt to reproduce the patient's symptoms and to answer meaningful questions about urinary tract function. In older adults, special consideration should be given when the patient is unable to follow directions or answer questions. Can he or she stand or transfer to the commode? Do their physical and mental conditions warrant the risk? Will this test not only change the course of treatment, but will the benefit outweigh the risk (Yared & Gormley, 2015)? Most often, urodynamics can still be performed in these situations, provided the clinician performing the urodynamics has a clear understanding of the testing goals, the patient's limitations, and the creative ability to answer the specific urodynamic questions.

Discussion of Urodynamic Tests

There are multiple components of urodynamic testing. Each component has its primary function to be evaluated, along with specific indications, in the effort to answer important clinical questions (see Table 3).

Uroflow with Post-Void Residual

The uroflow test measures urine flow rates and voided volume (Chapple et al., 2009). During the uroflow test, urine is measured in milliliters per second (ml/s), which is plotted against time; data are then converted to a graph tracing. Uroflow tests are often followed by a measurement of PVR. The information obtained from the uroflow study and the PVR can be useful in evaluating the general effectiveness of voiding, but it is not sufficient to determine the cause of lower urinary tract or voiding dysfunctions (Gray, 2010).

The following parameters should be measured and reported during uroflow testing:

* Voided volume: Total amount of urine voided.

* Total voiding time: Includes times of interruption.

* Flow time: Actual voiding time, not including times of interruption.

* Maximum flow rate: Milliliters per second as Qmax.

* Time to maximum flow.

* Average or mean flow rate: Qmean and is volume voided divided by flow time.

* Post-void residual: Obtained by bladder scan or straight catheterization.

* Flow pattern: Continuous or intermittent, smooth arc shaped curve or fluctuating curve (see Figures 2, 3, and 4).

Filling Cystometry

Filling cystometry measures pressure and volume relationships during bladder filling (Winters et al., 2012). Filling cystometry provides information and answers questions regarding bladder capacity, bladder wall compliance, bladder stability, and patient sensations during filling. Information about urethral sphincter competency can also be obtained during urodyna mic stress tests or urethral pressure measurements (see Table 4).

Cystometric capacity is the bladder volume at the end of the filling (Abrams et al., 2003). Normal bladder capacity for adults ranges from 300 to 600 ml. Capacity occurs during cystometrogram (CMG) filling when the patient is unable to tolerate more fluid and is given permission to void, or when the patient experiences a bladder contraction that results in bladder emptying. Using the patient's voiding diary history can be helpful in estimating the patient's expected CMG capacity. CMG filling rate, patient anxiety, and the patient's naturally accumulating urine volume can all affect CMG capacity and should be considered when interpreting urodynamic data.

Bladder compliance refers to the distendibility of the bladder wall. It describes the relationship between the change in bladder volume and the change in detrusor pressure during the filling CMG (Abrams et al., 2003). Bladder compliance can be expressed as a value and can be calculated by change in bladder volume, divided by change in detrusor pressure from the beginning to the end of fill or C =[DELTA]V/[DELTA][P.sub.det] (Winters et al., 2012). Bladder compliance can also be determined by visually inspecting the slope of the detrusor ([P.sub.det]) during filling CMG. Healthy bladders tend to maintain low detrusor pressure from the start of fill to completion of fill. Conversely, detrusor tracings in a bladder with low compliance will demonstrate a gradual increase in slope.

Low bladder compliance is most often associated with neurogenic bladder disorders, but it can also be secondary to conditions such as interstitial cystitis, pelvic irritation, or radical prostatectomy. Low bladder compliance is clinically relevant, particularly when associated with a high detrusor leak point pressure (discussed later in the article); this can cause upper urinary tract distress leading to ureteral reflux, hydronephrosis, upper UTIs, renal scaring, and sometimes loss of renal function.

During testing, patients should be asked to state certain feelings at specific phases of bladder filling. According to Abrams et al. (2002), three sensation parameters should be recorded during cystometry. The first sensation of filling (FSF) is when the patient feels an awareness that the bladder is filling. The first desire to void (FDV) is when the patient gets the urge to urinate, but feels voiding can wait until a restroom is available or the patient is asked to void. In this phase, the bladder will continue to fill without discomfort to the patient. When the patient feels and expresses a strong desire to void (SDV) without the fear of incontinence, this too should be documented as such.

Other documentation that is used in describing sensations would include the following:

* Normal--The patient is aware the bladder is being filled and expresses feelings of FSF until SDV that occurs at maximum cystometric capacity, which according to Abrams et al., (2002), "is the volume at which the patient feels he/she can no longer delay micturition (has a strong desire to void)."

* Increased--The patient has heightened awareness of filling and early SDV.

* Reduced--The patient tolerantly waits for FDV along with any positive response throughout filling. This can be documented as a reduced sensation or no sensation at all.

* Absent--The patient feels no sensation or desire to void throughout testing.

* Urgency--"A sudden compelling desire to void" (Abrams et al., 2002).

* Bladder pain--Stated as a subjective statement expressed by the patient. It is always abnormal (Abrams et al., 2002).

Increased urgency, or painful sensations during filling CMG, can be an indication of inflammation, infection, detrusor overactivity, neuralgia, and more. Reduced or absent sensations are most often indicative of neuralgia but can also be the result of overextension (Abrams et al., 2003). The patient's voiding diary can be a valuable resource (Jimenez-Cidre et al., 2015). Comparing that information to the observed sensations during cystometry can be very important when reporting subjective responses by the patient that could be influenced by anxiety and other factors, such as catheter discomfort and/or position.

Stability is a measurement of detrusor function during filling cystometry. Generally, there is little or no change in detrusor pressure during the filling process. Detrusor overactivity is when the bladder does not accommodate filling without change in pressure. Detrusor overactivity is an involuntary contraction of the detrusor muscle during the filling phase of urodynamics (Abrams et al., 2003). An unstable or overactive detrusor during the filling phase of the CMG can be reported as:

* With or without leak.

* With or without sensory awareness.

* Spontaneous or provoked.

* Neurogenic or idiopathic in cause.

* Phasic or terminal. Phasic detrusor overactivity is characterized by wave form, usually occurs multiple times throughout filling, and may or may not lead to incontinence. Terminal detrusor overactivity is a single detrusor contraction that happens at cystometric capacity, which results in incontinence and usually complete bladder emptying.

Detrusor overactivity can be associated with a number of specific neurological disorders common to the geriatric population, such as Parkinson's disease, stroke, and Alzheimer's disease (Aydemir, Adiguzel, & Yilmaz, 2016; Kim et al., 2015; Lee, Cho, Na, Ko, & Park, 2014). It can also be caused by many non-neurological disorders, such as cystitis, BPH, or other obstructive disorders (Xu et al., 2014). Detrusor overactivity can also be idiopathic or undetermined (see Figures 5, 6, and 7).

The competency of the urethral sphincter can be measured with urodynamic testing. Useful measurements include leak point pressures identified by both detrusor function and stress testing, as well as urethral pressures.

Urodynamic Stress Test Or Leak Point Pressure

The urodynamic stress test is used for any physical effort of the person being tested to elevate abdominal pressure during cystometry, with the aim of documenting stress urinary incontinence. The leak point pressure (LPP) measured during the stress test can be recorded as cough LPP, valsalva LPP, or abdominal LPP. The urodynamic stress test is done during the filling phase of urodynamics, generally at 150 to 200 ml of infused volume. The International Continence Society recognizes that evidence is lacking or conflicting with regard to the preferred technique of urodynamic stress testing, so the provocation method, the catheter size, the type of pressure measuring and the method of leak detection should always be reported (Rosier et al., 2016). According to Gray (2011b), low LPPs can be indicative of intrinsic sphincter deficiency (ISD) or urethral incompetence. This is usually less than 60 cm [H.sub.2]O (Gray, 2011b). Higher leak point pressures are generally associated with urethral hypermobility. Each condition is treated differently. When a patient presents with a prolapse and no SUI symptoms, reducing the prolapse during the cough and Valsalva phase of testing, it may uncover an occult SUI (see Case Study #2).

The older adult patient frequently presents with mixed incontinence. Often the patient cannot articulate how, when, or what he or she is doing when leaking occurs. Advanced age and menopausal status often correlate with intrinsic deficiency (Yared & Gormley, 2015). In these situations, urodynamics is helpful in order to treat the more severe problem first in the most efficient way (see Figures 8 and 9).

Urethral Pressure Test (UPP)

Urethral competency can be determined by measuring urethral pressure, or the amount of pressure needed to open the urethra. Urethral pressure studies differentiate between genuine stress incontinence caused by bladder neck hypermobility and incontinence caused by ISD. The UPP should be performed when the bladder contains at least 50 ml of minimum volume (Gray, 2011b). Actual technique is based on type of catheter used along with other specialized equipment.

Measurements most frequently recorded are:

* Urethral pressure profile (UPP): A graph indication intraluminal pressure along the length of the urethra. (Hayden et al., 2010).

* Maximum urethral pressure (MUP): The maximum pressure measured in the urethra.

* Maximum urethral closure pressure (MUCP): The maximum difference between the urethral pressure and the intravesical pressure (Pura[P.sub.ves]).

* Functional profile length: The length of the urethra along which the urethral pressure exceeds the intravesical pressure. This can be tested at rest or under stress.

* Pressure "transmission" ratio: The increment in urethral pressure on stress as a percentage of the simultaneously recorded increment in intravesical pressure (Hayden et al., 2010).

The following International Continence Society (ICS) and International Urogynecological Association (IUGA)-recommended terms should be used when reporting urethral mechanism (Hayden et al., 2010; Lose et al., 2002):

* Normal urethral closure mechanism occurs when no incontinence was demonstrated during ALPP tests and positive urethral closure pressure was maintained during bladder filling, even in the presence of increased abdominal pressure.

* Incompetent urethral closure mechanism is leakage observed during ALPP or during activities that raise the intraabdominal pressure.

* Urethral relaxation incompetence ("urethral instability," formerly referred to as intrinsic sphincter deficiency) is leakage due to urethral relaxation observed during urody namics in the absence of raised ALPP or a detrusor contraction. This generally coincides with maximum urethral closure pressures less than 20 cm [H.sub.2]O.

* Urodynamic stress incontinence is the involuntary leakage of urine during filling cystometry and is associated with increased intra-abdominal pressure in the absence of a detrusor contraction.

When performing UPP studies on patients with prolapse (uterine, cystocele, enterocele, or rectocele), the prolapse should be reduced in a manner that will not place anterior pressure, possibly obstructing the urethra that could produce a false higher UPP reading. Careful attention should be taken with the technique used to reduce the prolapse; use of a speculum, swab, forceps, manual, and pessary are common methods of prolapse reduction (Mahdy & Ghonium, 2014). Urethral pressures should be done with two to three pulls for comparison and average measurements (see Figure 10).

Detrusor Leak Point Pressure Test

Detrusor leak point pressure test (DLPP) evaluates storage pressures as they relate to low bladder compliance. DLPP is the lowest detrusor pressure at which urine leakage occurs in the absence of either a detrusor contraction or an increase in abdominal pressure (Rosier et al., 2016). In patients with neurogenic bladder, higher DLPP is more likely to be associated with upper track damage (McGuire et al., 1981). This is usually related to poor compliance with outlet obstruction (Gray, 2011a). In this case, urodynamics can be useful in determining safe bladder volumes to prevent reflux (see Figure 11).

Pressure Flow Studies

The pressure flow study measures the relationship between pressure in the bladder and urine flow rate during emptying. According to Abrams et al. (2002), for urodynamic practice, the "pressure-flow study begins immediately after permission to void and ends when the detrusor pressure has returned to the baseline value and/or the flow rate to zero and/or the patient considers the micturition completed. Note that pressure-flow analysis is only validated for voluntarily initiated micturitions and not for incontinence" (Rosier et al., 2016, p. 10). Its purpose is to investigate bladder contractility and urethral resistance as they relate to the emptying phase of micturition (see Table 2).

The process of voiding has been described by Abrams et al. (2002) "in terms of detrusor and urethral function and assessed by measuring urine flow rate and voiding pressures" (p. 169). This process requires a coordinated effort by the bladder and brain connected by neural circuits in the spinal cord to work effectively. For normal bladder emptying to occur, the bladder must contract adequately, and the urethra must relax and be free of anatomic obstruction. Normal voiding is achieved by a voluntarily initiated continuous detrusor contraction that leads to complete bladder emptying within a normal time span and in the absence of obstruction. For a given detrusor contraction, the magnitude of the recorded pressure rise will depend on the degree of outlet resistance. The amount of detrusor pressure required to empty the bladder is dependent on outlet resistance. In the male and female, there are obvious structural differences. Males will require higher detrusor pressures than the female to empty the bladder completely. These differences result in different normal maximal pressures. In the adult male, the normal maximal detrusor pressure ranges from 15 to 40 cm [H.sub.2]O. In contrast, the adult female normal detrusor pressure ranges from 8 to 30 cm [H.sub.2]O. In men, it is not uncommon for detrusor pressures to increase with age due to prostate changes. Conversely, with women, detrusor pressures may decrease with age due to low urethral resistance, especially in the presence of SUI.

The detrusor contractility should be documented as normal, acontractile or underactive.

* Normal detrusor: Contraction that is able to complete bladder emptying in the absence of obstruction (see Figure 12).

* Acontractile detrusor: Absence of contraction during pressure flow study.

* Underactive detrusor: A bladder contraction that does not allow for complete emptying of the bladder (see Figure 13).

Pressure flow studies can be used to determine if voiding dysfunctions are structural (bladder outlet obstruction) or functional (detrusor hypocontractility or acontractility) (see Figure 14). The information gained from pressure flow studies (treatment options for hydronephrosis or urinary retention, for example) might be determined from the results of pressure flow studies, especially if there is neurogenic pathology present. For example, prior to surgical intervention (transurethral resection of the prostate [TURP]) on a patient with known BPH, who also presents with urinary retention and severe diabetic neuropathy, the pressure flow study can be performed to prove obstruction (structural problem) and rule out atonic or hypotonic bladder (functional problem). On a female being evaluated for stress incontinence surgery, the pressure flow study might be clinically relevant when there is history of urinary retention or coexisting neurologic condition.

Griffiths (2014) developed graphic representations or "nomograms" used in identification and categorization of male outlet obstruction. Griffiths' (2014) nomograms, the LinPurr and the ICS nomograms, are most commonly seen in urodynamics studies.

Electromyogram

Electromyogram (EMG) studies the bioelectric potentials of muscles. The purpose of EMG during urodynamics is to determine whether pelvic floor muscles and the external urethral sphincter are coordinated or discoordinated with the bladder during filling and emptying. A normal response to bladder filling is a gradual increase in EMG recruitment. There will most often be an increase in EMG response during cough, valsalva, or other stress-provoking maneuvers. It is normal for pelvic floor muscles and urethral sphincter to relax during voiding, which would be observed as decreased in EMG activity.

Urodynamic EMG can be performed using surface electrodes, wire electrodes, or con centric needles. EMG can be useful in determining voiding dysfunctions that could include voluntary contraction of pelvic floor or abdominal straining during voiding. In patients with neurogenic disorders, EMG is used to diagnosing detrusor sphincter dyssynergia (DSD). In this scenario, the EMG tracing would show intermittent recruitment with simultaneous intermittent flow and increases in detrusor pressure. This pattern is often referred to as the "shark tooth" pattern (see Figure 15).

Discussion

The elderly population needs special considerations when performing urodynamics (Mahdy & Ghonium, 2014). Communication should be a key element in determining whether or not urodynamics is appropriate. Sensory deficits, such as hearing and vision loss, in addition to altered mental status, should be a main consideration prior to starting urodynamics. Many older adults are on multiple medications. Reviewing all medications that may have an effect on the lower urinary tract is very important because they may affect the test results. Some medications may include antimuscarinics, alpha-blockers, alpha agonists, antispasmodics, or medications for Parkinson's disease, to name a few. On the other hand, if determining efficacy of medications is a consideration of testing, it should so be noted and taken into consideration when interpreting the results.

Anxiety regarding any diagnostic testing may already exist with older adults due to mobility limitations and comorbidities. Positioning the patient for comfort, safety, and to avoid the fear of falling is very important; ideally, the patient should be in a seated position. Many patients have comorbid maladies that predispose them to difficult positioning (i.e., post-stroke patients, patients with Parkinson's disease, and patients with severe spinal stenosis/disk herniation or back pain). Special care should be taken to properly position these patients for the best outcomes (Yared & Gormley, 2015).

Finally, normal aging changes, such as urogenital atrophy, vaginal stenosis, and enlarged prostate, can make catheter insertion technically difficult and painful. Proper lighting and lubrication of the catheter can be helpful. Using a Coude catheter in the male can help make catheter passage more comfortable.

Antibiotic Use Prior To Urodynamic Testing

Antibiotic prophylaxis has been an area of debate for years, and advanced age is considered high risk for any invasive testing. Prevention of UTI is very important in this population because the risk for bacteremia in older adults can potentially have grave results. The antimicrobial agents of choice are fluorquinolones or trimethoprim/ sulfamethoxazole (Mahdy & Ghonium, 2014). If the patient is allergic to both of these medications, alternative antibiotics include amoxicillin/calvulanate, first- or second-generation cephalosporin, or aminoglycosides/ ampicillin (Mahdy & Ghonium, 2014). Antibiotics post-procedure have been proven effective to prevent UTI (Rahardjo, Tirtayasa, Afriansyah, Parikesit, & Akbar, 2016).

Conclusions

Urodynamics in the geriatric patient can be successfully performed with precision and efficiency by a trained technologist with the understanding of geriatric syndromes and their contribution to the results of the testing. These tests can be performed safely without undue morbidity if proper precautions are taken prior and during testing. It is most important to make a judicious decision with regard to performing testing in the first place. Only if testing will alter the course of treatment or facilitate symptom relief should these tests be performed. A general understanding of normal aging changes in the bladder is important for proper interpretation.

Case Studies

Case Study #1

An 83-year-old female patient was referred to urology for chronic urinary tract infection (UTI). she has history of a sling 10 years ago, colon cancer with radiation, has a colostomy, lumbar spine degeneration, and surgery with neurologic deficits in lower extremities, presumed to be second to radiation. she complains of difficulty voiding and leakage without sensory awareness, and she uses three large pads per day (see Figures below).

Uroflow: For the uroflowmetry, the patient voided 29 ml with a maximum flow of 1 ml/sec and an average flow of 3 ml/sec. A post-void residual of 500 ml was recorded.

CMG: For the cystometrogram, a 7 Fr urodynamic catheter was placed. The patient indicated a first sensation of filling with 628 ml of fluid within the bladder. The first desire to void was reported at 666 ml bladder volume. A strong desire was reported at 676 ml volume. At 678 ml infused volume, the patient reported the feeling of reaching bladder capacity.

A stress test was performed at the following bladder volumes:

* 402 ml with a calculated leak point pressure (LPP) of 72 and a [P.sub.ves] pressure of 112 cm [H.sub.2]O with cough.

* 402 ml with a calculated LPP of 24 and a [P.sub.ves] pressure of 70 cm [H.sub.2]O with valsalva.

* 402 ml with a calculated LPP of 40 and a [P.sub.ves] pressure of 85 cm [H.sub.2]O with cough.

During the pressure flow segment of testing, the patient voided 272 ml with a maximum flow rate of 2 ml/s and a maximum detrusor recording of 13 cm [H.sub.2]O. The average flow rate was 6 ml/s, with a remaining value of 399 ml representing post-void residual.

Urodynamic results: The cMG reveals large capacity, delayed sensation, stress urinary incontinence (sUi), and overflow incontinence. The pressure flow study reveals acontractile detrusor. The patient voids only a small amount by straining. Most of the bladder volume remains after void is complete.

Plan: The patient will be instructed on self-catheterization.

Case Studies (continued

Case Study #2

This 80-year-old female patient has a history of pelvic organ prolapse, frequency, urgency, hesitancy, and feeling of incomplete emptying. she denies leakage. she also has history of Parkinson's disease.

Uroflow: For the uroflowmetry, the patient voided 272 ml with a maximum flow of 15 ml/s and an average flow of 6 ml/s. A post-void residual of 60 ml was recorded.

CMG: For the cystometrogram, a 7 Fr urodynamic catheter was placed. The patient indicated a first sensation of filling with 153 ml of fluid within the bladder. The first desire to void was reported at 257 ml bladder volume. A strong desire was reported at 290 ml volume. At 400 ml infused volume, the patient reported the feeling of reaching bladder capacity.

A stress test was performed at the following bladder volumes:

* 208 ml with a leak peak pressure (LPP) of 126 cm H20, and the patient did not leak with cough and unreduced.

* 208 ml with a calculated LPP of 84 and a [P.sub.ves] pressure of 118 cm H20 with cough when cystocele reduced.

* 208 ml with an LPP of 64 cm H20 and the patient did not leak with Valsalva and cystocele reduced.

* 208 ml with a calculated LPP of 93 and a [P.sub.ves] pressure of 120 cm H20 with cough when cystocele reduced.

* 208 ml with an LPP of 99 cm H20, and the patient did not leak with cough when cystocele reduced.

During the pressure flow segment of the test, the patient voided 350 ml with a maximum flow rate of 16 ml/s and a maximum detrusor recording of 10 cm [H.sub.2]O. The average flow rate was 8 ml/s, with a remaining value of 50 ml representing postvoid residual. The detrusor pressure during this voiding study was very low but also subject to artifact from change in abdominal pressure upon position change from standing to sitting. There does, however, appear to be a curve in the detrusor tracing.

Urodynamic results: The CMG reveals normal capacity and sensation, stable bladder, and positive stress urinary incontinence (SUI) when prolapse was reduced (occult SUI). The pressure flow revealed normal flow pattern, low voiding pressure, and PVR of 50 ml.

Plan: The patient desires conservative treatment. Will try a pessary and possible pelvic floor physical therapy.

Case Study #3

This 80-year-old male patient is being evaluated for urgency, frequency, nocturia, and retention. He is being evaluated for obstructive benign prostatic hyperplasia (BPH) and possible transurethral resection of the prostate (tUrP). His history also includes diabetes mellitus with peripheral neuropathy.

Uroflow: For the uroflowmetry, the patient voided 299 ml with a maximum flow of 20 ml/s and an average flow of 7 ml/s. A post-void residual of 500 ml was recorded.

CMG: For the cystometrogram, a 7 Fr urodynamic catheter was placed. The patient indicated a first sensation of filling with 393 ml of fluid within the bladder. The first desire to void was reported at 396 ml bladder volume. The patient experienced an uninhibited detrusor contraction at this time, which he was unable to suppress. Therefore, capacity was determined.

During the pressure flow segment of the test; the patient voided 16 ml with a maximum flow rate of 3 ml/s and a maximum detrusor recording of 80 cm [H.sub.2]O. The average flow rate was 3 ml/s, with a remaining value of 378 ml representing postvoid residual.

Urodynamic results: cMG reveals normal capacity, decreased sensation, and overactive detrusor without leak. The pressure flow reveals high pressure, slow flow rate, relaxed EMG, and significant post-void residual. Nomograms indicate obstructive range (Xu et al., 2014).

Plan: Transurethral resection of the prostate (TURP).

doi: 10.7257/1053-816X.2017.37.3.127

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Shin, Y.S., On, J.W., Kim, M.K. (2015). Effect of aging on urodynamic parameters in women with stress urinary incontinence. Korean Journal of Urology, 56(5), 393-397.

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Xu, D., Cui, X., Qu, C., Yin, L., Wang, C., & Chen, J. (2014). Urodynamic pattern distribution among aged male patients with lower urinary tract symptoms suggestive of bladder outlet obstruction Journal of Urology, 83(3), 563-569.

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Christine Koops and Leslie S. Wooldridge

Christine Koops, BSN, RN, is the Owner, Dynamic Measurements, LLC, Grand Rapids, MI.

Leslie S. Wooldridge, GNP-BC, CUNP, is Director, Mercy Health Bladder Clinic, Muskegon, MI.

Caption: Figure 1. Examples of "Failure to Store" and "Failure to Empty" as They Relate to the Bladder and Outlet

Caption: Figure 2. Normal Uroflow Note: This was a 60-year-old man without voiding symptoms. The patient voided 333 ml, and his maximum flow rate (Qmax) was 28.0 ml/s.

Caption: Figure 3. Decreased Flow Rate Note: This was an 82-year-old woman with diabetes mellitus with recurrent urinary tract infections and a residual urine volume of 175 of 150 ml. The uroflow demonstrated a voided volume of 322 ml and a maximum flow rate (Qmax) of only 10.2 ml/s. The low uroflow is abnormal, but it cannot differentiate among progressive impaired detrusor contractility with aging or diabetes mellitus.

Caption: Figure 4. Straining Uroflow Note: The maximum flow rate was normal (Qmax = 29.0 ml/s), and this 85-yearold woman did not have any residual urine. However, the uroflow pattern is consistent with abdominal straining. The urinary stream occurs in spurts with complete interruption between the spurts. This pattern of "Valsalva voiding" points out the value of looking at the uroflow pattern in addition to just the numeric readout.

Caption: Figure 5. Urodynamic Study Urge Incontinence with Detrusor Overactivity Note: Arrow denotes involuntary detrusor contraction with leakage.

Caption: Figure 6. Phasic Detrusor Overactivity

Caption: Figure 7. Terminal Detrusor Overactivity

Caption: Figure 8. Cystometrogram Demonstrating Abdominal Leak Point Pressure Test Note: Shows cough leak point pressure of 146 cm H20 (190 minus baseline Pves of 44) and Valsalva leak point pressure of 87 cm [H.sub.2]O (132 minus baseline Pves of 45).

Caption: Figure 9. Example of Intrinsic Sphincter Deficiency Note: cystometrogram demonstrating abdominal leak point pressure test, showing Valsalva leak point pressure of 41 cm [H.sub.2]O (79 minus baseline [P.sub.ves] of 37) and cough leak point pressure of 27 cm [H.sub.2]O (64 minus baseline [P.sub.ves] of 37).

Caption: Figure 11. Illustration of Low Bladder Compliance Note: This 72-year-old man with T12 level spinal cord injury leaked at a detrusor leak point pressure of 50 cm [H.sub.2]O at 300 ml despite maximal anti-muscarinic bladder medications.

Caption: Figure 12. Illustration of normal female pressure flow study, where the patient voided with a normal flow, a maximum detrusor voiding pressure of 24 cm [H.sub.2]O, and voided volume of 542 ml to complete emptying. Note: This 72-year-old man with T12 level spinal cord injury leaked at a detrusor leak point pressure of 50 cm [H.sub.2]O at 300 ml despite maximal anti-muscarinic bladder medications.

Caption: Figure 13. Illustration of an underactive detrusor contraction in a male patient who was suspected to have obstructive BPH, but pressure flow study reveals underactive detrusor. Note: The study shows a slow flow rate (Qmax 4 ml/s), a maximum detrusor voiding pressure of 148 cm [H.sub.2]O, voided volume of 186 ml, and incomplete emptying with a post-void residual of 442 ml.

Caption: Figure 14. Illustration of a Pressure Flow Study from a Male Patient with Obstructive Benign Prostatic Hyperplasia Note: In this study, the patient voided with a slow flow rate (Qmax 5 ml/s), a maximum detrusor voiding pressure of 14 cm H20, and voided volume of 148 ml and incomplete emptying with a post-void residual of 198 ml.

Caption: Figure 15. EMG Pattern Demonstrating Detrusor Sphincter Dyssynergia (DSD) with the Classic Shark Tooth Pattern
Table 1. Urology Assessment Tools

Name                        Description         Indications and Aims

Urine dip stick       A basic diagnostic        To determine presence
                        tool used to              or absence of a
                        determine                 urinary tract
                        pathological changes      infection (UTI),
                        in a patient's urine.     hematuria, and
                                                  glycosuria.
Urinalysis with       An electronic tool        To determine presence
  or without            used to determine         of absence of
  culture               pathological changes      a UTI.
                        in a patient's urine.
Bladder diary         Chart used by the         To evaluate voiding
                        patient to record         patterns, quantify
                        volume and time of        severity of
                        each void, fluid          symptoms and add
                        intake, pad usage,        objectivity to the
                        and incontinence          history in
                        episodes.                 evaluating patients
                                                  with LUTs.
LUTS questionnaires   Patient-completed         To summarize LUTs and
                        questionnaires for        the impact of
                        evaluating lower          symptoms, to
                        urinary tract             evaluate
                        symptoms (LUTS) and       effectiveness of
                        their impact on           treatment, to
                        quality of life.          facilitate
                                                  patient-clinician
                                                  discussion, and
                                                  used in
                                                  epidemiological
                                                  surveys.
supine stress test    During physical           To confirm evidence
                        examination or after      of stress
                        retrograde filling        incontinence.
                        of the bladder, the
                        patient is asked to
                        cough while the
                        examiner visualizes
                        the urethral meatus
                        and notes presence
                        or absence of
                        leakage.
Q-Tip test            Measures the change in    To confirm the
                        angle of a patient's      presence or absence
                        urethra during a          of urethral
                        Valsalva maneuver         hypermobility in
                        using a lubricated        evaluating the
                        cotton swab and a         possible cause of
                        protractor-measuring      stress
                        device. Urethral          incontinence.
                        hypermobility is
                        considered if the
                        change in angle from
                        relaxed to Valsalva
                        is greater than
                        30 degrees.
Pad test              Measures the volume of    Used to detect and
                        leakage during a          quantify
                        specific period of        urine loss.
                        time based on pad
                        weight (1 ml
                        = 1 gm).
Pyridium pad test     The patient is given      Used to detect and
                        Pyridium prior to         quantify urine
                        the pad test to           loss.
                        determine if
                        moisture is indeed
                        urine leakage.
Tampon test/          Oral Pyridium is given    Used to identify
  double dye test       to the patient,           extra urethral
                        methylene blue and        leakage and to
                        sterile water are         determine the
                        instilled into the        source of extra
                        bladder, and a            urethral leakage
                        tampon is placed          (e.g., vesicle/
                        vaginally. The            vaginal fistula or
                        tampon is later           urethral/vaginal
                        inspected for the         fistula).
                        presence and
                        color of dye.
Cystoscopy            Cystoscopy is an          Used to evaluate the
                        endoscopic procedure      cause of hematuria,
                        that uses a flexible      irritative bladder
                        scope inserted            symptoms, or
                        through the urethra       frequent UTIs.
                        to visualize the          Used to diagnose
                        lower urinary             urethral strictures
                        tract--the urethra,       or bladder cancer.
                        the external              Used for procedural
                        sphincter, the            purposes, such as
                        prostate, and             to remove bladder
                        the bladder.              tumors, bladder
                                                  stones, and
                                                  ureteral stones, or
                                                  to place or remove
                                                  ureteral stents.

Source: Reprinted from Koops, 2016. Copyright
2016 Springer. Reprinted with permission.

Table 2. Classification System for Bladder Storage and Emptying

                      Failure to Store             Failure to Empty

Bladder          Urge incontinence/detrusor     Underactive bladder
                   overactivity                   (hypotonic, atonic)
                   overflow incontinence/poor
                   compliance
Outlet/urethra   Stress incontinence            Obstruction (BPH,
                                                  strictures,
                                                  prolapse) dsd
                                                  (detrusor
                                                  sphincter
                                                  dyssnergia)

Source: Adapted from Wein, 1981.

Table 3. Components of Urodynamics

Name (Abbreviation)        Primary Function         Description
                            Being Evaluated

Uroflow                   Global voiding        Electronic
                            function.             measurements
                                                  of urine flow
                                                  rates and voided
                                                  volume.

Post-void                 Global voiding.       Amount of urine
  residual (PVR)            function              remaining in the
                                                  bladder after
                                                  void. Measured by
                                                  catheterization
                                                  or ultrasound.

Cystometry                Storage function      Commonly used to
  (CMG) Also                and sensation of      describe the
  known as                  the bladder.          filling phase of
  filling cystometry                              urodynamics. This
                                                  is a measurement
                                                  of infused
                                                  volume, pressures
                                                  ,and sensation.

Urodynamic stress         ALPP (VLPP, dPP,      Urodynamic stress
  test or abdominal         stress leak)          test is when any
  leak point pressure       --urethra             physical effort
  (ALPP) often              competence.           is made by the
  referred to as:                                 person being
  Valsalva leak point                             tested to
  pressure (VLPP),                                increase intra
  cough leak point                                -abdominal
  pressure (cLPP),                                pressure. ALPP is
  or stress leak                                  the intravesical
                                                  pressure at which
                                                  urine leakage
                                                  occurs due to
                                                  an increased
                                                  abdominal pressure
                                                  (from cough,
                                                  Valslava, or
                                                  stress-provoking
                                                  maneuver) in the
                                                  absence of a
                                                  detrusor
                                                  contraction.
Detrusor leak             DLPP--urethral        DLPP is defined as
  point pressure (DLPP)     competence in         the lowest
                            regards to            detrusor pressure
                            elevated storage      at which leakage
                            pressures.            occurs in the
                                                  absence of either
                                                  a detrusor
                                                  contraction or
                                                  increased
                                                  abdominal
                                                  pressure.

Urethral pressure         Urethral competence   Pressure
  profile (UPP)             and closing           measurements
                            functions.            taken from all
                                                  points along the
                                                  urethra, which
                                                  are reproduced in
                                                  the form of a
                                                  profile. These
                                                  measurements can
                                                  be taken at rest
                                                  or during stress
                                                  (coughing or
                                                  straining).
Pressure flow             Detrusor              Simultaneous
  study (PFs)               contractility         measurements of
                            and bladder           bladder pressure
                            outlet during the     and flow rates
                            voiding phase.        taken during the
                                                  voiding phase of
                                                  multi-channel
                                                  urodynamics.

Electromyography          coordination of       A graphic
  (EMG)                     pelvic floor          representation of
                            contraction           the electrical
                            during filling        activity of the
                            and stress and        urethral sphincter
                            relaxation of         or pelvic floor
                            pelvic floor          muscles during
                            during void.          multi-channel
                                                  urodynamics.

Fluoroscopic              Simultaneous          Combines and links
  urodynamics               observation of        radiographic
                            the morphology        imaging with
                            and function of       urodynamic
                            the lower urinary     pressure, flow
                            tract.                and EMG tracings.

Name (Abbreviation)        Indications
                            and Aims

Uroflow                   Used to identify
                            voiding patterns
                            when voiding
                            dysfunction
                            associated with
                            LUTS is suspected.
Post-void                 Used to evaluate
  residual (PVR)            sufficiency of
                            bladder emptying
                            when voiding
                            dysfunction
                            associated with
                            LUTs is suspected.
Cystometry                Used to identify
  (CMG) Also                abnormalities in
  known as                  bladder capacity,
  filling cystometry        compliance,
                            stability, and
                            sensation in
                            patients with LUTS,
                            particularly when
                            history of previous
                            pelvic surgery,
                            suspected
                            neurological
                            involvement, failure
                            of conservative
                            treatment, or
                            complicated history
                            is present.
Urodynamic stress         ALPP (VLPP, CLPP,
  test or abdominal         stress leak)--used
  leak point pressure       to determine
  (ALPP) often              urethral competence
  referred to as:           and quantify
  Valsalva leak point       urethral
  pressure (VLPP),          incompetence when
  cough leak point          stress incontinence
  pressure (cLPP),          is suspected.
  or stress leak
Detrusor leak             DLPP--along with
  point pressure (DLPP)     associated
                            cystometric filling
                            volume, DLPP is
                            used to determine
                            safe balder
                            volumes, typically
                            in patients with
                            suspected neurogenic
                            urinary tract
                            dysfunction, for
                            the purpose of
                            protecting the upper
                            tracts from
                            sustained elevated
                            storage pressures.
Urethral pressure         Generally performed
  profile (UPP)             by gynecologists
                            and urogynecologists
                            to determine
                            urethral competence
                            and rule out
                            intrinsic sphincter
                            deficiency when
                            evaluating
                            symptoms of
                            incontinence.
Pressure flow             Used to determine the
  study (PFs)               cause of abnormal
                            urine flow or
                            elevated post-void
                            residual
                            (obstruction vs.
                            detrusor under
                            activity). sometimes
                            used to evaluate the
                            cause of urgency
                            symptoms.
Electromyography          Used to determine
  (EMG)                     coordination between
                            the detrusor function
                            and the pelvic floor
                            during bladder
                            filling and during
                            the voiding phase
                            when detrusor
                            sphincter
                            dyssynergia or
                            neurological
                            involvement are
                            suspected with
                            regards to LUTs or
                            to evaluate the
                            integrity of the
                            pelvic floor.
Fluoroscopic              Used to identify
  urodynamics               abnormalities in
                            bladder storage or
                            outlet when
                            complicated
                            pathology is
                            expected or when
                            diagnosis is unclear
                            after simpler tests
                            have been performed.

Source: Adapted from Koops, 2016. Copyright 2016
Springer. Reprinted with permission.

Table 4. Summary of the Five Essential Functions and
Their Associated Reportable Urodynamic Findings

Function              Urodynamic Findings

Capacity     * Large (> 600 ml).
             * Normal (300 ml to 600 ml).
             * small (< 300 ml).
Compliance   * High bladder wall compliance
               (often considerably greater
               than 30 ml/cm [H.sub.2]O).
             * Normal bladder wall
               compliance (> 30 ml/cm
               [H.sub.2]O).
             * Low bladder wall compliance
               (< 10 cm [H.sub.2]O).
Competency   * competent sphincter
               mechanism (no measureable
               abdominal leak point pressure).
             * Incompetent urethral
               sphincter mechanism
               (urodynamic stress urinary
               incontinence with measurements
               often seen with maximum
               urethral closure pressure
               [less than or equal to]
               20 cm [H.sub.2]O).
Sensations   * Increased sensations
               (sensations of bladder
               filling occur at low
               volumes).
             * Reduced sensations (delayed
               and diminished sensations
               of bladder filling).
             * Absent bladder sensations
               (no sensation of bladder filling).
Stability    * Stable/normal (no overactive
               detrusor contractions
               during bladder filling).
             * Detrusor overactivity
               (one or more detrusor
               contractions with or without
               associated urge, and with
               or without associated leak
               during bladder filling).

Source: Adapted from Gray, 2012, p. 22.

Figure 10. Example of Urethral Pressure Profile (UPP)

                              Pull 1      Pull 2

Length                           4           4
Start                          16.5        26.1
End                            21.2        30.7
Peak                            61          66
Obstruction Zone Peak            0           0
Length of continence Zone        2           2
Area of continence Zone         83          101
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Title Annotation:Advanced Clinical Practice
Author:Koops, Christine; Wooldridge, Leslie S.
Publication:Urologic Nursing
Date:May 1, 2017
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