Video-urodynamics P J R Shah Institute of Urology and UCH
Bladder Function Storage Capacity and Pressure Emptying Pressure/flow/emptying
URODYNAMIC INVESTIGATIONS Free urine flow rate Urethral pressure profilometry Cystometry Videocystometry EMG Ambulatory urodynamics
Flow Rate
Stricture Before Urethrotomy
Cystometrogram Standard Urodynamics Filling: Rate of filling Volume of first sensation Bladder capacity when full or involuntary emptying started Cough leakage Pressure recorded during filling Overactivity
CMG Voiding: Upright effects Initiation of voiding Voiding stream Ability to interrupt stream Volume voided Residual volume
CMG Idiopathic Detrusor Overactivity
CMG Exclude bladder instability (OAB) in simple stress incontinence Confirm BOO in men But doesn t show the site of the obstruction Confirm instability (OAB) in simple urge incontinence Poor compliance
Advantages of CMG Simple Readily available No radiation Least expensive
Disadvantages of CMG No visualisation of anatomy Unstable bladder (OAB) can be missed in up to 56% No grading of stress incontinence
Indications for CMG Simple stress incontinence before surgery BOO or irritative LUTS in male
Video urodynamics
Videourodynamics is the Gold Standard All of CMG plus Grading of stress incontinence Visualisation of anatomy Video = I see Non-video = I do not see Richard Turner-Warwick
VCMG Sphincter function Site of any obstruction - Vesico-ureteric reflux Trabeculation/ sacculation Diverticula Other structural abnormalities
Video-Urodynamics Imaging + UDS Correlate CMG with anatomy GSI (Blaivas, VLPP) Vesical abnormalities Neuropathic bladder abnormalities (DLPP) Congenital abnormalities Previous reconstruction
Are there disadvantages of VCMG? Radiation dose should be minimal with modern capture techniques May miss up to 56 % OAB but depends on rate of fill Needs training in screening
Video-Urodynamics 500ml/hour fluid po before test Flow rate 6F urethral and rectal catheters System box Patient marker (void, urge, incontinence) Electronic nappy
Indications for VCMG Previous failed stress incontinence surgery Irritative LUTS following stress incontinence surgery Neuropathic bladder dysfunction Hyperreflexia Reduced Compliance Poor Voiding Bladder Neck/Sphincter Abnormalities Congenital anomalies Previous reconstructive surgery Complex BOO (?DSD) All patients with stress incontinence prior to surgery*
Videourodynamics in Stress Incontinence Position of bladder neck Is the bladder neck open at rest/cough/strain? Does the bladder neck descend? What is the state of the urethra during void? Can the patient do a stop test?
Urodynamic Tracing from Female with GSI
Videourodynamics demonstrating stress urinary incontinence
Video screening in GSI demonstrating increasing descensus with coughing
Blaivas McGuire Raz Type 0 History of stress but no objective evidence Type 0 No true SUI Anatomical due to malposition of intact sphincter unit Type 1 Bladder neck and urethra open and descend < 2cm during stress Type 11A Bladder neck and urethra open and descend > 2cm during stress with cystocele Type 11B Bladder neck and urethra below symphysis at rest Type 111 Bladder neck and urethra are open at rest in the absence of detrusor contraction Type 1 SUI, minimal hypermobility +/- cystocele. UCP > 20 cm H 2 O Type 11 SUI with marked hypermobility UCP > 20 cm H 2 O Type 111 Prior failed surgery UCP < 20 cm H 2 O Intrinsic sphincter dysfunction due to malfunction of the sphincter +/- hypermobility
Blaivas Type I Video-Urodynamics in SUI
Blaivas Type IIb Video-Urodynamics in SUI
Blaivas Type III Video-Urodynamics in SUI
Vesico-vaginal Fistula Cystoscopy and EUA bilateral ureterograms 3 swab test (+ methylene blue) plus or minus VCMG
URODYNAMICS IN DETRUSOR HYPERREFLEXIA Measure residual urine pressure Fill at slow rate 10-20ml/min Screen for bladder appearance and for DSD Measure both pressure height and duration Drain bladder at end of study and measure volume
Detrusor Hyperreflexia
CMG demonstrating poor bladder compliance
VLPP The pressure that causes leakage of urine in the absence of a detrusor contraction 150-200ml or 50% cystometric capacity Standing If > 150 cm H20 then urethra unlikely to be cause of incontinence McGuire et al, 1993
VLPP VLPP < 60 cm H20 75% type III SUI VLPP > 90 cm H20 type I and II SUI Pabd or Pdet absolute or subtracted? Volume 150 ml (McGuire), 250 ml or half functional capacity (Haab) Catheter size Prolapse with and without reduction (Ghoneim)
UPP Intraluminal pressure along the urethra Static or stress Both lack specificity and sensitivity McGuire 1995
Urethral Pressure Profile Perfusion catheter technique Perfused at constant rate - 2 ml/min Catheter slowly withdrawn (match to speed of measuring system) General catheter speed @5mm/s