Urodynamics: focus on the geriatric patient.
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).
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 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 (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).
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).
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 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).
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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.|
|Date:||May 1, 2017|
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