Table Of ContentGiancarlo Vignoli
Urodynamics
A Quick Pocket Guide
123
Urodynamics
Giancarlo Vignoli
Urodynamics
A Quick Pocket Guide
Giancarlo Vignoli
Functional Urology Unit
Casa Madre Fortunata Toniolo
Bologna
Italy
ISBN 978-3-319-33758-6 ISBN 978-3-319-33760-9 (eBook)
DOI 10.1007/978-3-319-33760-9
Library of Congress Control Number: 2016953671
© Springer International Publishing Switzerland 2017
P artially based on the Italian language edition: Urodinamica: Quick
Pocket Guide - tutto ciò che devi sapere in 120 pagine, ElleQ Editore, 2013.
© Prof. Vignoli
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Pref ace
Since its introduction 30 years ago, urodynamics has produced
practical and clinically relevant data in the field of urology
and gynecology with significant impact on patient care.
I n the last few years, the idea that urodynamics is a complex,
ambiguous, and confusing investigation whose answers often
do not satisfy the expectations is raised. In addition, it is an
invasive technique, sometimes poorly tolerated by the patient.
D espite this unwarranted criticism, no scientific society
denied its value. Conversely, all agree that it represents a
necessary step before any surgical approach to incontinence
and obstruction.
U rodynamics requires skill not only in the conduct and
interpretation of the tests but also in the setup and calibra-
tion of the equipment for each procedure. It is therefore
advisable that these studies are performed by competent
practitioners.
“ Good urodynamic practice” should comprise at least
three elements: (1) a clear indication for and appropriate
selection of relevant test measures and procedure, (2) precise
measurement with data, and (3).accurate analysis and critical
reporting of results. Training in urodynamics is not currently
standardized. It is obtained from various sources, mostly
courses run by varying associations, but also senior colleagues
and even companies who developed the equipment. Several
surveys of personnel performing urodynamics had shown that
half of the responders thought that their training had been
inadequate. There are several books on urodynamics, and
some are really excellent. However, the impression that you
get visiting the different urodynamic units is that there are a
vi Preface
lot of academics but little practice. Paradoxically, when one
talks with young doctors, medical researchers, nurses, and
technicians who usually perform urodynamic investigation,
often the sophisticated criticism on knowing the use of a
single test but not the basic rules for its execution is perceived.
Many practitioners, for example, are unable to do properly
essential procedures like transducers zeroing to atmospheric
pressure. In this context, the equation “difficult = no useful” is
the predictable consequence and may account, in part, for the
recent reappraisal of the clinical role of urodynamics. Nothing
could be more wrong, since urodynamics refers in fact to a
series of simple tests designed to produce, alone or in combi-
nation, useful information for a specific clinical situation. Not
all patients require a complex study, i.e., multichannel urody-
namics; in many cases, a simple, noninvasive approach includ-
ing uroflow and post-residual urine may be sufficient to clarify
the patient’s complaints. The goal of this pocket booklet is to
increase the level of confidence and ability with standard uro-
dynamic techniques bridging the “gap” between science and
clinical practice. The book is arranged in a very practical way
avoiding a detailed description of the basic science and the
complex physiology behind the urodynamics. The main goal is
to draw the reader’s attention on the appropriate selection of
the tests and their correct performance with a special concern
to troubleshooting and artifacts and, finally, to interpretation
of the results. To facilitate the consultation keeping the text
easy, additional explanatory footnotes have been included to
strengthen the main concepts. Furthermore, since the primary
aim of the book is to describe the urodynamic techniques,
there is a limited discussion about the diagnosis and treatment
of the specific clinical conditions. At the end of each chapter,
a selected list of more recent reviews on the topic is reported
for further reading.
Bologna, Italy Giancarlo Vignoli
Acknowledgments
S pecial thanks to my wife Claudia and my friend Mr. Vanni
Ogliani for collaboration and valuable suggestions.
Contents
1 The Framework of Basic Science. . . . . . . . . . . . . . . . 1
1.1 What Is Urodynamics?. . . . . . . . . . . . . . . . . . . . 1
1.2 The Micturition Cycle. . . . . . . . . . . . . . . . . . . . . 1
1.3 The Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2 Key Symptoms Analysis and Diagnostic
Algorithms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1 Storage Symptoms. . . . . . . . . . . . . . . . . . . . . . . . 10
2.2 Increased Daytime Frequency. . . . . . . . . . . . . . 10
2.3 Urgency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.4 Nocturia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.5 Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . 17
2.5.1 Stress Incontinence . . . . . . . . . . . . . . . . . 17
2.5.2 Urge Incontinence. . . . . . . . . . . . . . . . . . 24
2.5.3 Mixed Urinary Incontinence . . . . . . . . . 25
2.6 Nocturnal Enuresis . . . . . . . . . . . . . . . . . . . . . . . 26
2.6.1 Terminology . . . . . . . . . . . . . . . . . . . . . . . 26
2.6.2 The Path to Becoming Dry. . . . . . . . . . . 26
2.7 Giggle Incontinence . . . . . . . . . . . . . . . . . . . . . . 28
2.8 Painful Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2.9 Voiding Symptoms. . . . . . . . . . . . . . . . . . . . . . . . 30
2.9.1 Voiding Symptoms in Adult Men . . . . . 31
2.9.2 Voiding Symptoms in Young Men. . . . . 31
2.9.3 Voiding Symptoms in Women . . . . . . . . 32
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3 Physical Examination and Laboratory Tests . . . . . . 37
3.1 Abdominal Palpation . . . . . . . . . . . . . . . . . . . . . 37
3.2 Vaginal Examination. . . . . . . . . . . . . . . . . . . . . . 37
x Contents
3.2.1 POP-Q. . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.2.2 Q-Tip Test. . . . . . . . . . . . . . . . . . . . . . . . . 40
3.3 Pelvic Floor Muscle (PFM) Testing. . . . . . . . . . 42
3.4 Rectal Examination. . . . . . . . . . . . . . . . . . . . . . . 43
3.5 Focused Neurological Examination . . . . . . . . . 43
3.6 Laboratory Evaluation . . . . . . . . . . . . . . . . . . . . 46
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4 Urodynamic Testing: When and Which. . . . . . . . . . . 49
4.1 When Is Urodynamic Testing Indicated?. . . . . 49
4.2 Which Testing Should Be Selected? . . . . . . . . . 50
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5 Voiding Diary and Pad Testing . . . . . . . . . . . . . . . . . 53
5.1 Voiding Diary. . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.2 Pad Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
5.2.1 1-h Pad Test. . . . . . . . . . . . . . . . . . . . . . . . 55
5.2.2 24-h Pad Test. . . . . . . . . . . . . . . . . . . . . . . 56
5.2.3 Interpretation. . . . . . . . . . . . . . . . . . . . . . 56
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6 Noninvasive Urodynamics . . . . . . . . . . . . . . . . . . . . . 59
6.1 Uroflowmetry. . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
6.1.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . 59
6.1.2 Techniques of Measurement. . . . . . . . . . 60
6.1.3 How to Read a Flow Curve . . . . . . . . . . 61
6.1.4 Artifacts. . . . . . . . . . . . . . . . . . . . . . . . . . . 66
6.2 Uroflowmetry in Pediatric Age
(<15 Years). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
6.3 The Value of Free Flowmetry in the
Diagnosis of Bladder Outlet Obstruction
(BOO) in Male . . . . . . . . . . . . . . . . . . . . . . . . . . 73
6.4 Advantages and Disadvantages of
Uroflowmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
6.5 Post-void Residual Urine (PVR). . . . . . . . . . . . 74
6.5.1 Normal Values of the Post-void
Residual. . . . . . . . . . . . . . . . . . . . . . . . . . . 74
6.6 New Noninvasive Urodynamic
Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Contents xi
6.6.1 Bladder/Detrusor Wall
Thickness (DWT). . . . . . . . . . . . . . . . . . . 76
6.6.2 Penile Cuff Compression
Techniques . . . . . . . . . . . . . . . . . . . . . . . . 76
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
7 Invasive Urodynamics. . . . . . . . . . . . . . . . . . . . . . . . . 81
7.1 Conventional Urodynamics . . . . . . . . . . . . . . . . 81
7.1.1 The Equipment. . . . . . . . . . . . . . . . . . . . . 81
7.1.2 Urodynamic Manufacturers and
Choice of the Equipment . . . . . . . . . . . . 84
7.1.3 The Catheters. . . . . . . . . . . . . . . . . . . . . . 87
7.2 Preparation of the Patient . . . . . . . . . . . . . . . . . 91
7.2.1 Setup of the Patient, Step by Step. . . . . 91
7.2.2 Microtip and Air-Charged Catheters . . 95
7.3 Filling Phase (Cystometry). . . . . . . . . . . . . . . . . 96
7.3.1 Detrusor Function . . . . . . . . . . . . . . . . . . 97
7.3.2 Urethral Function . . . . . . . . . . . . . . . . . . 105
7.3.3 Quality Control of Recording
at the End of Filling Phase. . . . . . . . . . . 108
7.4 Voiding Phase (Pressure-Flow Study) . . . . . . . 108
7.4.1 Definitions . . . . . . . . . . . . . . . . . . . . . . . . 109
7.4.2 Common Artifacts During Pressure-
Flow Study: Recognitions and
Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . 117
7.5 Pressure-Flow Study in Pediatric Age . . . . . . . 121
7.5.1 Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
7.5.2 Filling Phase . . . . . . . . . . . . . . . . . . . . . . . 124
7.5.3 Voiding Phase. . . . . . . . . . . . . . . . . . . . . . 125
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
8 Electromyography of Pelvic Floor Muscles . . . . . . . 129
8.1 Types of Electrodes and Setup . . . . . . . . . . . . . 130
8.1.1 Checking the Correct Position
of the Electrodes . . . . . . . . . . . . . . . . . . . 133
8.1.2 Common Artifacts. . . . . . . . . . . . . . . . . . 133
8.1.3 Normal EMG Activity During
Micturition Cycle. . . . . . . . . . . . . . . . . . . 135
8.1.4 Abnormal EMG Patterns. . . . . . . . . . . . 135
