Diagnostic Evaluation of Lower Urinary Tract Dysfunction

1. Diagnostic Evaluation of Lower Urinary Tract Dysfunction Victor W. Nitti, MD Professor and Vice Chairman Department of Urology NYU School of Medicine

2. Lower Urinary Tract Function • Storage of urine at low pressure to protect kidneys and assure continence • Voluntary evacuation of urine

3. Lower Urinary Tract Function • Can be viewed anatomically • Bladder • Outlet • Can be viewed functionally • Storage • Voiding

4. Functional Classification ofVoiding Dysfunction • Problem with emptying • Problem with storage • Either of the above may be due to • Bladder dysfunction • Bladder outlet or urethral dysfunction *Wein, 1982

5. Storage Symptoms Frequency Urgency Incontinence Stress Urgency Nocturia “Pain” Emptying Symptoms Slow stream Need to strain Hesitancy Intermittency Feeling of incomplete emptying Lower Urinary Tract Symptoms

6. Other Sequelae of LUT Dysfunction • Urinary retention • Recurrent UTI’s • Hydronephrosis • Renal insufficiency

7. History Physical Ancillary tests Urine Analysis PVR Uroflow * Diaries * Pad test * Urodynamics Radiography Cystoscopy Evaluation of Lower Urinary Tract Dysfunction Videourodynamics

8. History • Symptoms • Characterization • Duration • Severity • Response to treatments or other factors • Effect of activities and QoL • Can use symptom scores

9. History • Voiding Habits • Fluid Intake • Bowel habits • Sleeping pattern • Hematuria • UTI’s • Vaginal symptoms

10. History • Urologic • Ob/Gyn • Neurologic • Medical / surgical • Social / psych • Radiation • Pelvic trauma • Medications

11. Physical Exam • Abdominal exam • Pelvic Exam • vaginal mucosa • atrophy • prolapse • assess 3 levels • presence/grade • Muscular integrity • assess ability to squeeze • assess strength of squeeze • Provocative stress test

12. Evaluation - Physical • Rectal Exam • Tone • Posterior compartment prolapse • Rectal masses • Anal sphincter integrity • Neurologic assessment • Overall coordination • MMS • Sensation • Reflexes

13. Urine Analysis • UTI • Hematuria • Specific Gravity • Proteinuria • Glucosuria

14. Voiding and Intake Diaries • Very useful tool to evaluate LUTS • Correlate history with reality • Number of voids, incontinence episodes, urgency and severity, nocturia • Assess fluid intake and urine output • Determine • Avg. voided volume • Max. voided volume • Nocturnal vs. daytime urine production • Nocturnal polyuria

15. Voiding and Intake Diary(Frequency/Volume Chart)

16. Pad Test • Use when it is important to quantify the amount of urine loss • Can be done under specific conditions, i.e. stress pad test, or to mimic typical day • Stress pad test • 20 minute • 1 hour • 24 hour

17. Post Void Residual • Excellent assessment of emptying • Ultrasound (bladder scan) or catheterization • Results may prompt further investigation

18. Uroflow • Uroflowmetry with the measurement of PVR urine is recommended as a screening test for symptoms suggestive of urinary voiding dysfunction ($th ICI, 2008) * • Voiding symptoms • Elevated PVR • Results may prompt further investigation • Consider shape on curve not only Qmax, Qavg, etc.

19. Abdominal straining pattern Normal Uroflow Flattened or obstructed pattern Interrupted Pattern

20. Cystoscopy • LUT endoscopy highly recommended (4th ICI) • When initial testing suggest other pathologies, e.g. hematuria • When pain or discomfort features in the patient’s LUTS : these may suggest an intravesical lesion • When appropriate in the evaluation of vesicovaginalfistula and extra-urethral urinary incontinence

21. Imaging • Upper Urinary Tract • Renal Ultrasound • CT scan • MRI • Lower Urinary Tract • MRI • CT scan • Cystography • Pelvis • Ultrasound • Transvaginal • Abdominal • CT scan • MRI

22. Imaging • Imaging of the upper urinary tract is highly recommended in specific situations (4th ICI, 2008) • Hematuria • Neurogenic urinary incontinence e.g. myelodysplasia, spinal cord trauma, • Incontinence associated with significant post-void residual • Co-existing loin/kidney pain • Severe pelvic organ prolapse, not being treated • Suspected extra-urethral urinary incontinence • Urodynamic studies which show evidence of poor bladder compliance

23. Role of Urodynamics • Level 1 evidenced-based “indications” for its use are surprising lacking • Difficult to conduct RCTs • For conditions where lesser levels of evidence and expert opinion strongly suggest clinical utility • Were “empiric treatment” is potentially harmful or even life-threatening (e.g. neurogenic voiding dysfunction) • Symptoms can be caused by a number of different conditions and it is difficult to study pure or homogeneous patient populations

24. Role of Urodynamics • Given the current state of evidence for UDS studies, what is most important is that the clinician has clear cut reasons for performing the study and that the information obtained will be used to guide treatment of the patient • Therefore it is more useful to describe the role of UDS in clinical practice rather than precise “indications” for its use

25. Practical Use Of Urodynamics • UDS is most useful when history, physical exam and simple tests are not sufficient to make an accurate diagnosis and/or institute treatment

26. Practical Use Of Urodynamics • Clinical applicability in two general scenarios: • To obtain information needed to make an accurate diagnosis for what condition(s) is causing symptoms (e.g. lower urinary tract symptoms or incontinence) • To determine the impact of a disease that has the potential to cause serious and irreversible damage to the upper and lower urinary tract, sometime without symptoms • Neurological diseases, radiation cystitis

27. Role of UDS in Clinical Practice4th ICI, 2008 • To identify or rule out factors contributing to lower urinary tract dysfunction (e.g. urinary incontinence) and assess their relative importance • To obtain information about other aspects of lower urinary tract function or dysfunction • To predict the consequences of lower urinary tract dysfunction on the upper urinary tract Hosker G, et al : Dynamic Testing. In: Incontinence 4th International Consultation on Incontinence. United Kingdom, Health Publications, 2009, pp. 413-552.

28. Role of UDS in Clinical Practice4th ICI, 2008 • To predict the outcome, including undesirable side effects, of a contemplated treatment • To confirm the effects of intervention or understand the mode of action of a particular type of treatment (especially a new one) • To understand the reasons for failure of previous treatments for symptoms (e.g. urinary incontinence) or for lower urinary tract function in general. Hosker G, et al : Dynamic Testing. In: Incontinence 4th International Consultation on Incontinence. United Kingdom, Health Publications, 2009, pp. 413-552.

29. UrodynamicsPreparation • Decide on questions to be answered before starting the study • Design the study to answer these questions • Customize the study as necessary

30. UrodynamicsGuidelines • A study not duplicating symptoms when an abnormality is recorded is not diagnostic • Failure to record an abnormality does not rule out its existence • Not all abnormalities are clinically significant

31. UrodynamicsPhases of Micturition Cycle • Storage or filling phase • Cystometrogram (CMG) • Provocative maneuvers • ALPP • Urethral pressure measurements • Emptying • Voiding pressure - flow study • Urethral sphincter or pelvic floor electromyography (EMG) • Post void residual

32. Cystometry • CMG is measurement of the bladder’s response to filling • Filling pressure • Sensation • Involuntary contractions • Compliance • Capacity • Control over micturition

33. Idealized Normal Adult CMG Filling and Storage Voiding Pressure Volume

34. Cystometry • CMG only assesses the bladder’s response to filling • Many abnormalities of filling and storage are caused by abnormalities of voiding • If CMG alone is done, underlying problem maybe missed

35. CMG Multichannel Urodynamics

36. Multichannel Urodynamics • Bladder pressure monitoring (Pves) • Abdominal pressure monitoring (Pabd) • Subtracted detrusor pressure (Pdet) • Urethral pressure monitoring* • EMG • Voiding pressure / flow study- Contractility - Pressure - flow relationship (obstruction) - Emptying

37. Urodynamic Parameters • Filling and Storage • Sensation and capacity • Involuntary detrusor contractions • Idiopathic detrusor overactivity • Neurogenic detrusor overactivity • May be spontaneous or provoked

38. Involuntary Detrusor Contractions

39. Urodynamic Parameters • Filling and Storage • compliance • ml/cm H20 • Absolute pressure probably more important than a compliance number or value • Storage pressures > 40 cm H2O known to be harmful (McGuire, et al, 1981) • Impaired compliance usually a result of outlet obstruction (anatomical or functional) or structural changes like radiation cystitis or TB

40. Impaired Compliance

41. Impaired Compliance + IDC

42. A Problem With Compliance:These two are not the same cmH2O cmH2O 50 5 400 40 mL mL Compliance = 8 ml/cmH2O Compliance = 8 ml/cmH2O

43. Impaired Compliance 40 ml. 280 ml. 330 ml. 400 ml. Impaired Compliance & IDC’s Pves = 40 cm H20 80 ml. 160 ml.

44. Urodynamic Parameters • Storage • Leak point pressures • Abdominal or Valsalva (ALPP) • Bladder or detrusor (BLPP) • Urethral pressure profile • MUP • MUCP

45. Abdominal Leak Point Pressure • Abdominal pressure required to cause urinary incontinence in the absence of a detrusor contraction (AKA Valsalva LPP) • Measure of intrinsic sphincter function • Ability of bladder outlet to resist changes in abdominal pressure • Used to evaluate stress incontinence • Normal intrinsic sphincter function • No leak at any physiologic Pabd • No “normal ALPP”

46. Leakage at arrow = ALPP = 109cmH2O

47. Detrusor Leak Point Pressure • Detrusor pressure required to cause urinary incontinence in the absence of an increase in abdominal pressure (AKA Detrusor LPP) • Impaired compliance • Involuntary contractions • Bladder’s response to increased outlet resistance • DESD • Other causes of bladder outlet obstruction

48. Leakage at arrow = BLPP = 45 cmH2O

49. Detrusor Leak Point Pressure • DLPP > 40 cm H2O is potentially dangerous to the upper tracts!

50. Urodynamic Parameters • Emptying • Obstruction or impaired contractility • Detrusor contractility • Sphincter coordination • Bladder neck / internal sphincter • Striated sphincter • DESD • Dysfunctional voiding