Abrams' Urodynamics

Marcus Drake, Hashim Hashim, Andrew Gammie, Marcus Drake, Hashim Hashim, Andrew Gammie

• Publisher: Wiley-Blackwell
• Year: 2021
• ISBN:
  9781118844731
• Edition: 4
• Topic: Médecine
• Subtopic: Hématologie

Abrams' Urodynamics

A complete guide to urodynamic investigation in modern health care

Urodynamic testing is an ever-advancing field with applications in the management of patients from across a wide range of clinical areas. Bringing together fundamental principles and cutting-edge innovations, Abrams' Urodynamics has been designed as an all-in-one guide to Functional Urology and Urogynecology, offering direct, up-to-date instruction on how to best perform and understand urodynamic tests within the overall treatment pathway. Its chapters cover everything from everyday basic practice to advanced complex cases, and are enhanced with more than 450 helpful illustrations. Including numerous revisions and new features, this fourth edition of the book boasts:

• Coverage of all investigative approaches, including uroflowmetry, cystometry, video-urodynamics, and non-invasive techniques
• Details on the successful running of a urodynamic unit, with information on organizational issues, equipment set-up, and common problems and pitfalls
• Sections addressing children, women, men, the elderly, and neuropaths
• Extensive description of International Continence Society (ICS) Standards throughout
• Appendices that include ICS Standards and Fundamentals documents, ICIQ modules, and Patient Information Leaflets

With its wealth of clinical tips, illustrations, new innovations, and hands-on advice, Abrams' Urodynamics is essential reading for all those wishing to better integrate urodynamic testing into their daily practice.

Part I
Basic Principles

1
Basic Urodynamics and Fundamental Issues

Marcus Drake¹, Andrew Gammie², Laura Thomas³, Arturo García‐Mora⁴, and Hashim Hashim²

¹ Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK

² Bristol Urological Institute, Southmead Hospital, Bristol, UK

³ Urodynamics & Gastrointestinal Physiology, Southmead Hospital, Bristol, UK

⁴ Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Hospital Médica Sur, Mexico City, México

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CONTENTS

• Introduction to Urodynamics
  • The Urodynamic History and Examination
  • The Aims and Considerations of Urodynamics
• Basics of Urodynamics
  • What Is Urodynamics?
  • What Is Measured?
  • Setting Up the Equipment
  • Running the Test
  • Troubleshooting
• Fundamentals
  • ‘Occult’ Neurological Disease
  • How a Urodynamic Trace Should Be Presented
  • Adhering to High Standards
  • Safety of the Urodynamics Staff
• A Brief History of Urodynamics
• Summary
• References

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Introduction to Urodynamics

Urodynamics has two basic aims:

• To reproduce the patient's symptomatic complaints while making key observations
• To provide a pathophysiological explanation by correlating the patient's symptoms with the urodynamic findings

These two basic aims are crucial to the purpose of urodynamics – essentially, it is a diagnostic test that will aid in the management of patients. The need to make urodynamic observations reflects the fact that the patient's symptoms are important, but they might be somewhat misleading. Most patients with lower urinary tract dysfunction (LUTD) present to their doctor with symptoms. However, lower urinary tract symptoms (LUTS – Table 1.1) should not simply be taken at face value, since a range of differing mechanisms may result in rather similar symptomatic presentations. The statement ‘the bladder is an unreliable witness’ [2] reflects how symptoms are the starting point but do not actually identify the ultimate explanation. Since treatment should correct the underlying cause, it is necessary to identify mechanisms, avoiding assumption or prejudice coming from taking symptoms at face value. An excellent example of this is voiding LUTS in men, where the cause on urodynamic testing may prove to be bladder outlet obstruction (BOO) and/or detrusor underactivity (DUA); BOO should respond fully to surgery to relieve obstruction such as transurethral resection of prostate (TURP), while such surgery is potentially not helpful in the second [3]. Voiding LUTS in males are of unreliable diagnostic value, and only slow stream and hesitancy show any correlation with the urodynamic findings of BOO [4–6]. Even with flow rate assessment, one cannot be sure whether BOO is present (Figure 1.1). The difficulty of assessing LUTD by symptoms alone is the uncertainty about establishing truly what is going on in the individual describing them.

Table 1.1 Classification of lower urinary tract symptoms (LUTS) [1].

Source: Modified from Abrams et al. [1].

Storage	Voiding	Post‐micturition
Urgency	Slow stream	Post‐micturition dribbling
Urinary incontinence	Splitting/spraying	Feeling of incomplete emptying
Increased daytime frequency	Intermittency
Nocturia	Hesitancy
Pain	Straining
	Terminal dribbling

Note: Do NOT forget to enquire about Pelvic Organ Prolapse in Women and Erectile Dysfunction in Men.

Figure 1.1 Flow rate testing in men gives an uncertain understanding. This man had previously done a free flow rate test which showed a reasonable maximum flow rate of 16 ml/s; taken alone, this might suggest he does not have bladder outlet obstruction (BOO). However, when he attended for urodynamics (see the pressure‐flow study illustrated above), his flow rate was 15 ml/s as shown, but the pressure needed to achieve this was high, indicating BOO is present (see Chapter 14 for more details on assessing BOO in men).

For women diagnosed by their symptoms as having stress urinary incontinence (SUI), only 50–68% have urodynamic stress incontinence (USI) [7, 8]. These studies also looked at patients with apparent overactive bladder (OAB) symptoms presumed to be the result of detrusor overactivity (DO), and here, the correspondence was 33– 51%. A key factor is the link to coughing, often used as a question to elicit a history of SUI; if a woman says ‘I leak when I cough’, it sounds like SUI. However, a cough can be a trigger to set off an overactive detrusor contraction, leading to detrusor overactivity incontinence (DOI) (Figure 1.2). Thus, the history may suggest that SUI treatment is needed, but for some of these women, the urodynamic observation identifies that DO treatment is the appropriate choice.

Figure 1.2 A woman who reported leakage with coughing in her history, suggestive of stress urinary incontinence (SUI). Her urodynamic test showed cough‐provoked detrusor overactivity (DO) incontinence, and she described this as representative of her presenting complaint. Hence, this is not urodynamic stress incontinence, but effort‐provoked detrusor overactivity incontinence; the symptomatic presentation was misleading and could have led to inappropriate surgery for SUI (see Chapter 13 for more details on assessing incontinence in women).

Accordingly, in both men and women, there is potential mismatch between reported LUTS and the LUTD identified by detailed investigation. This issue is particularly prominent in people with neurological conditions and children. In neurological disease, it is common for sensation to be absent or abnormal, making LUTS even more difficult to interpret. Children may find it difficult to des...