Topic 1:Assessment Chair: Professor Ralf Tunn, Germany

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2 Topic 1:Assessment Chair: Professor Ralf Tunn, Germany

3 Klinik und Poliklinik für Geburtshilfe Urodynamics: why and when G. Naumann Dep. of Obstetrics and Gynecology J. Gutenberg-University Mainz Germany mainz.de

4 Klinik und Poliklinik für Geburtshilfe Is there any need for Urodynamics? Pro Yes! Urodynamics try to enhence What causes the increased voiding the understanding of lower frequency in this patient? urinary tract functioning and to reveal the underlying Why does this patient have urinary pathology causing patients incontinence? complaints. Glazener, C. M. and Lapitan, M. C.: Urodynamic investigations for management of urinary incontinence in adults. Cochrane Database of Systematic Reviews,

5 Klinik und Poliklinik für Geburtshilfe Is there any need for Urodynamics? Pro Contra Yes! Urodynamics There were no try statistically to enhence What causes the increased voiding signicant the understanding differences of in lower clinical frequency in this patient? incontinence urinary tract outcomes functioning in terms and to of cure rates, reveal pad the tests underlying and number Why does this patient have urinary pathology of incontinence causing episodes. patients incontinence? complaints. Glazener, C. M. and Lapitan, M. C.: Urodynamic investigations for management of urinary incontinence in adults. Cochrane Database of Systematic Reviews,

6 Role of urodynamic studies Klinik und Poliklinik für Geburtshilfe identify factors contributing to the LUT dysfunction (e.g. UI) and assess their relative importance obtain information about other aspects of LUT dysfunction predict the consequences of LUT dysfunction for the upper urinary tract predict the outcome, including undesirable side effects, of a contemplated treatment confirm the effects of intervention or understand the mode of action of a particular type of treatment understand the reasons for failure of previous treatments for urinary incontinence, or for LUT dysfunction in general. 6

7 Why we do urodynamic studies Klinik und Poliklinik für Geburtshilfe UD is the only way to understand why people are continent or incontinent All gynecologists and urologists involved in urogynecology should be familiar with urodynamic studies UD is not the only answer part of specialized investigation (clinical examination, stress test, urine analysis, pelvic floor ultrasound e.g.) 7

8 Why we do urodynamic studies Klinik und Poliklinik für Geburtshilfe Investigator should understand their physical principles and potential pitfalls as well as proper standardization The doctor works with the machine, not the machine with the doctor 8

9 Conventional urodynamic studies Klinik und Poliklinik für Geburtshilfe Uroflometry Filling cystometry Pressure-flow studies (voiding cystometry) Urethral pressure profilometry Assessment of leak point pressure No technological innovations for 20yrs modern equipment with new hardware Rosier et al Executive Summary: The International Consultation on Incontinence 2008 Committee on: Dynamic Testing ; for Urinary Incontinence and for Fecal Incontinence. Part 1: Innovations in Urodynamic Techniques and Urodynamic Testing for Signs and Symptoms of Urinary Incontinence in Female Patients

10 Urodynamics in the Sixties Klinik und Poliklinik für Geburtshilfe 10

11 Klinik und Poliklinik für Geburtshilfe

12 Technological innovations of UDS Air-charged catheter Klinik und Poliklinik für Geburtshilfe may provide an acceptable alternative, comparative studies are undergoing objective method to assess bladder filling sensation useful, improves the reproducibility and sensitivity or specificity of UDS Non-invasive measurement of pressure and flow in men by penile cuff or condom urethral retro-resistance pressure no better information about urethral closure fct than UPP urethral pressure reflectometry need for more studies for clinical usefulness Rosier et al Executive Summary: The International Consultation on Incontinence 2008 Committee on: Dynamic Testing ; for Urinary Incontinence and for Fecal Incontinence. Part 1: Innovations in Urodynamic Techniques and Urodynamic Testing for Signs and Symptoms of Urinary Incontinence in Female Patients

13 When we do urodynamic studies Klinik und Poliklinik für Geburtshilfe UD continues to be the gold standard to define the pathophysiology of LUTD Not cost effective, requires specialized and expensive equipment and special training Not to recommend universal testing in all patients with uncomplicated UI 13

14 When we do urodynamic studies Klinik und Poliklinik für Geburtshilfe Non-invasive urodynamics Uroflowmetry and post-void residual simple, non-invasive should be performed on all pts. with incontinence or voiding dysfunction Voiding abnormalities such as Valsalva voidingor low flow rates may predict abnormal symptomatic voiding dysfunction postoperativley Ghoniem et al. Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice Int Urogynecol J (2008) 19:

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18 When we do urodynamic studies Klinik und Poliklinik für Geburtshilfe Invasive urodynamics Cystometry (recommended) most accurate tool for evaluation of bladder function with filling positive Cough test and single channel Cystometry may be the minimally accepted tests before intervention Ghoniem et al. Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice Int Urogynecol J (2008) 19:

19 When we do urodynamic studies Klinik und Poliklinik für Geburtshilfe Invasive urodynamics Multi-channel Cystometry requires expensive equipment and special training Advantages: allows determination of pressure-related fluid loss estimation of leak pressures multiple variables Ghoniem et al. Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice Int Urogynecol J (2008) 19:

20 When we do urodynamic studies Klinik und Poliklinik für Geburtshilfe Invasive urodynamics Multi-channel Cystometry requires expensive equipment and special training Disadvantages: repeatability is poor in non-neurogenic pt. repeated measures are suggested to establish bladder capacity and pressures Ghoniem et al. Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice Int Urogynecol J (2008) 19:

24 When we do urodynamic studies Klinik und Poliklinik für Geburtshilfe Invasive urodynamics Pressure flow study (optional) relationship between pressure in bladder and urine flow rate during emptying recommended to investigate voiding dysfunction - previous incontinence surgery - high residual urine volume Ghoniem et al. Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice Int Urogynecol J (2008) 19:

27 When we do urodynamic studies Klinik und Poliklinik für Geburtshilfe Invasive urodynamics Urethral pressure profilometry (optional) fluid pressure needed to just open a closed urethra Problems: do not discriminate urethral incompetence from other disorders do not provide a measure of severity Ghoniem et al. Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice Int Urogynecol J (2008) 19:

30 Klinik und Poliklinik für Geburtshilfe Value of urethral pressure profiles at rest (MUCP) There is much overlap between MUCP in continent and stress incontinent women, that this test hardly can be usful for diagnosis (4rd ICI) Hilton P., et al. Br J Obstet Gynaecol,

31 Klinik und Poliklinik für Geburtshilfe Value of urethral pressure profiles at rest (MUCP) cm H2O continent women occult light moderate severe women with stress incontinence Hilton P., et al. Br J Obstet Gynaecol,

32 Klinik und Poliklinik für Geburtshilfe Value of urethral pressure profiles at rest (MUCP) Ignoring urethral pressure mesasurement may lead to a less successful surgical intervention MUCP cutoff value < 20 cm H 2 O leads to continent rates < 15-30% Sand et al Burch-colposuspension MUCP < 20 cm H 2 O subj. cure rate 46% MUCP > 20 cm H2O subj. cure rate 82% 32

33 Klinik und Poliklinik für Geburtshilfe Value of urethral pressure profiles at rest (MUCP) Author Publication Method Behr GebFra 1986 Marshall-Marchetti Hilton Neurourol Urodyn 1983 Sling Hilton Brit J Obstet 1989 Burch Hilton Brit J Obstet 1991 Stamey Weil Brit J Obstet 1984 Burch Francis J Reprod M 1987 Burch Sand Am J Obstet Gynecol 1989 Burch Rezapour Int Urogyn J 2001 TVT 33

34 When we do urodynamic studies Klinik und Poliklinik für Geburtshilfe Invasive urodynamics Leak pressures (optional) Detrusor leak point pressure (DLPP) Abdominal leak point pressure (ALPP) ALPP is defined as the intravesical pressure at which urine leakage occurs due to increased abdominal pressure in absence of detrusor contraction ALPP < 60 cm H2O indicates intrinsic dysf. Ghoniem et al. Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice Int Urogynecol J (2008) 19:

35 When we do urodynamic studies Klinik und Poliklinik für Geburtshilfe Invasive urodynamics in prolapse Bump et al % of women with advanced POP have potential incontinence DU before surgery with reduction of prolapse can detect masked incontinence Ghoniem et al. Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice Int Urogynecol J (2008) 19:

36 When we do urodynamic studies Klinik und Poliklinik für Geburtshilfe Invasive urodynamics invasive or surgical treatment is considered Previous treatment for incontinence (surgical or non-surgical) has failed Voiding dysfunction Neurological disorder Unexplained incontinence Ghoniem et al. Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice Int Urogynecol J (2008) 19:

37 When we do urodynamic studies Klinik und Poliklinik für Geburtshilfe Mainz concept Stress urinary incontinence Cystometry (filling up to 300cc, no detrusor overactivity post-void residual < 50cc) Urethral pressure profilometry (MUCP >25 cm H 2 O, good urethra length) Optional uroflowmetry (in elder patient with bladder empty disorder) Optional pressure flow study 37

38 When we do urodynamic studies Klinik und Poliklinik für Geburtshilfe Mainz concept Overactive Bladder Cystometry (filling up to 300cc, detrusor overactivity) Optional pressure flow study (measurement of detrusor contractility) Important: predicting postoperative detrusor function 38

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