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.
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 â 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 â 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 âthe bladder is an unreliable witnessâ [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 [4â6]. 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
Postâmicturition
Urgency
Slow stream
Postâmicturition 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.
For women diagnosed by their symptoms as having stress urinary incontinence (SUI), only 50â68% 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 33â 51%. A key factor is the link to coughing, often used as a question to elicit a history of SUI; if a woman says âI leak when I coughâ, 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.
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...