Urodynamics Wieders + Flashcards
1
Q
What are the two phases of bladder function?
A
Filling (storage)
Emptying (voiding)
2
Q
What three things are required for bladder filling?
A
Absence of involuntary contractions
Accommodation
Closed bladder outlet
3
Q
What are the three components of bladder accommodation?
A
Compliance SNS stimulation (reduces detrusor tone) PNS inhibition (reduces detrusor tone)
4
Q
What two things are required to keep the bladder outlet closed during the filling stage?
A
SNS stimulation (increases smooth sphincter tone) Onuf's nucleus stimulation (increases striated tone)
5
Q
What 3 factors are required for normal emptying?
A
Absence of obstruction
Open bladder outlet
coordinated detrusor contraction
6
Q
What two factors are involved in opening the bladder outlet during the emptying phase?
A
SNS inhibition (decreases smooth sphincter tone) Onuf's nucleus inhibition (decreases striated tone)
7
Q
What two factors are involved in coordinated detrusor contraction?
A
PNS stimulation (Increases detrusor tone) SNS inhibition (decreases detrusor inhibition)
8
Q
What are the two major determinants of urine flow rate?
A
Detrusor function
Outlet resistance
9
Q
What is the guarding reflex?
A
Inhibition of PNS
Stimulation by SNS
Activation of Onuf’s nucleus
10
Q
What is the voiding reflex?
A
Bladder volume reaches critical level leading to:
Activation of PNS
Inhibition of SNS
Inhibition of Onuf’s nucleus
Can be suppressed and controlled by the cerebral cortex.
11
Q
What structure allows the CNS to allow voluntary voiding?
A
Barrington’s nucleus in the Pons.
12
Q
What are the seven components of a urodynamic study?
A
Cystometry Uroflowmetry Pressure flow studies Electromyography Urethral pressure profilometry Cystogram Post void residual
13
Q
What does uroflowmetry measure?
A
Flow rate
voided volume
voiding duration
14
Q
What is required for an adequate uroflometry study?
A
At least 150ml
15
Q
What does the graph of a normal flow profile look like?
A
Bell shaped curve
16
Q
What are the normal peak flow rates for men and women?
A
Men: 20-25 ml/sec
Female: 25-30 ml/sec
17
Q
What flow rates suggest obstruction?
A
Suspected obstruction: 10-15 ml/sec
Probable obstruction: < 10 ml/sec
18
Q
What is a normal PVR?
A
< 50-100cc
19
Q
What does an increased PVR indicate?
A
Bladder outlet obstruction
Decreased detrusor function
Both of the above.
20
Q
What 5 things does a CMG measure?
A
Detrusor pressure Bladder capacity Bladder compliance Voluntary sphincter function Leak point pressure
21
Q
What is a normal bladder compliance?
A
< 6 cm water rise in detrusor pressure with filling
22
Q
What is a normal volume for first sensation of filling?
A
100-200ml
23
Q
What is a normal volume for sensation of fullness?
A
350-450ml
24
Q
What is a normal volume for first desire to void?
A
350-450ml
25
What is volume of imminent void?
Unable to inhibit voiding any longer
26
What else should the patient be asked to do during a cystometrogram?
cough or valsalva
27
What is abdominal leak point pressure/valsalva leak point pressue?
The lowest intravesical pressure at which urine leaks around the catheter with an increase in abdominal pressure but no detrusor contraction.
28
What values are diagnostic for ALPP/VLPP?
ALPP < 60 indicates SUI caused by ISD
ALPP 60-100 is indeterminant
ALPP > 100 indicates that SUI is not from ISD
29
What is detrusor leak point pressure?
The lowest pressure at which urine leaks around the catheter without detrusor contraction and with no increase in abdominal pressure.
30
What values are important for detrusor leak point pressure?
DLPP > 40cm water can cause ureteral obstruction, hydronephrosis, and renal damage.
31
In what order should the phases of the UDS be read?
1. Filling phase
2. Voiding phase
3. Flow
4. Video cystogram
32
What should be evaluated when reading the filling phase?
```
Compliance
Capacity
Sensation
Detrusor overactivity
Urine leak
```
33
What is the equation of bladder capacity in kids?
(Age in years + 2) x 30 = bladder capacity in ml
34
What indicates significant detrusor overactivity?
If they are sensed
If they cause leakage
If they increase pressure > 15ml of water
35
What should be evaluated in the voiding phase?
```
Max flow
Voided volume
Max detrusor pressure (Pdet max)
PVR
EMG
```
36
What is normal Pdet max?
40-60cm water
| Less for females
37
What is the impact of a suprapontine lesion on voiding?
Detrusor overactivity
Bladder sphincter synergy
Normal sensation
Adequate emptying
38
What is the impact of a lesion in the pons to the spinal cord above S2?
Detrusor overactivity
Spastic sphincter
Detrusor sphincter dyssynergia
Spastic paresis of lower limbs
39
What is the impact of a lesion from S2-S4?
Acontractile flaccid detrusor
Flaccid striated sphincter
Flaccid paralysis of the lower limbs
40
What is the impact of a lesion to the peripheral pelvic nerves?
Acontractile detrusor
| Absent bladder sensation
41
What are the typical UDS findings of Multiple sclerosis?
Detrusor overactivity
42
What are the typical UDS findings of normal pressure hydrocephalus?
Detrusor overactivity
Dementia (wacky)
Gait disturbances (wobbly)
Urge incontinence (wet)
43
What are the typical UDS findings for stroke patients?
Detrusor overactivity
| Synergic sphincter
44
What are the typical UDS findings for Parkinson's disease?
Detrusor overactivity
| Usually no DSD but sometimes cogwheeling can cause DSD.
45
What are the typical UDS findings associated with Cauda equina syndrome?
Acontractile detrusor
| Flaccid sphincter
46
What are the typical findings for a patient with spinal shock from a suprasacral spinal cord injury?
Acontractile detrusor
Increased tone in urethral sphincter and bladder neck
Absent bulbocavernosus and deep tendon reflexes
47
How long does spinal shock usually last?
6-12 weeks
48
What are the typical UDS findings for a patient with tethered cord?
Detrusor underactivity
49
situations where UDS would be helpful - 5
1. failed TURP/ refractory luts, 2. failed incontinence procedure, 3. SUI and prolapse, 4. NGB, 5. post prostatectomy incontinence
50
what part of UDS evaluates detrussor function - 2
1. CMG, 2. DLPP
51
what parts of UDS evaluates SUI - 3
1. valsalva LPP, 2. flouro UDS, 3. urethral Pressure Profile
52
what parts of UDS evaluate outlet obstruction - 3
1. uroflow, 2. pressure flow, 3. flouro UDS
53
what parts of UDS eval neurogenic conditions - 3
1. CMG, 2. DLPP, 3. EMG
54
what is abrams griffiths nomogram
classification for BOO based on Qmax
55
Q max assd w/ BOO
< 10 ml/sec
56
Q max ruling out BOO
> 15 ml/sec
57
bladder vol and urine flow rate
max flow rate is volume dependent
58
what does nl PVR tell u
nl PVR = nl neurologic function and nl detrusor/ outlet relationship
59
what is nl pvr
< 50
60
def of " bladder voiding efficiency"
measures degree of bladder emptying aka measures bladder contractility vs outlet resistance
61
"bladder voiding efficiency" formula
voided volume/total bladder volume x 100
62
what # is abnormal for BE
< 75% correlates with detrussor failure
63
where is normal first sensation during CMG
75-150cc
64
nl bladder capacity
350-450 cc
65
2 phases of bladder filling
accommodation is flat curve, elastic phase is steep curve
66
main strength of CMG
allows measurement of compliance
67
% patients with nl CMG with DO
50%
68
compliance formula
change in vol over change in pressure
69
def pseudodyssenergia
voluntary contraction of external sphincter to prevent leakage in neurologically normal patient. True DSD only happens if neurologically abnormal
70
what type of LPP measures sphincteric incontinence
ALPP/VLPP (valsalva)
71
what does ALPP/ VLPP measure
measure bladder neck/ urethral competence with increased abdominal pressure - ability of sphincter to resist leakage
72
caveat of ALPP/VLPP
only measurable in ppl with SUI as nl people will not leak at any physiologic abdominal pressure
73
what LPP measures ability to store at low pressure
DLPP and BLPP (bladder)
74
DLPP def
intravesical pressure at the moment when fluid is first seen leaking from urethra around catheter. measures the "injured" bladder response to higher outlet resistance
75
what does DLPP tell you
> 40 cm H2O = risk of upper tract deterioration
76
ALPP/VLPP interpretation - 3
1. < 60 cm H2O assd w ISD, 2. 60-100 cm H2O - grey area, 3. > 100 cm H2O urethral hypermobility. the lower the ALPP, the weaker the sphincter
77
relationship of ALPP, ISD and urethral hypermobility
if there is no hypermobility, SUI must be caused by ISD regardless of ALPP
78
how to measure ALPP
1. insert catheter and measure PVR, 2. add/remove to 150-200 ml total, 3. have pt STAND then slow valsalva until leakage, 4. cough test ONLY if valsalva doesn’t work, 5. if still no leakage, remove catheter repeat valsalva/ cough
79
what is appropriate fill rate
50-75 ml/min
80
ALPP and full bladder
will maintain sphincter closed and give false negative
81
what is stress induced urge incontinence
stress incontinence with valsalva forces internal sphincter open which then causes contraction of external sphincter. Open bladder neck induces voiding response.
82
tx for stress induced urge incontinence
continence procedure - sling
83
anticholinergics and LPP
no effect on LPP
84
prolapse and UDS
have to reduce prolapse during uds
85
why do u have to reduce prolapse during uds
obtain accurate LPP because when treating prolapse may unmask SUI.
86
2 types of urethral leak point pressure
static and dynamic UPP
87
problem with static UPP
ISD is a dynamic problem
88
what is dynamic UPP
pull catheter as pt coughs
89
normal dynamic UPP
urethral pressure (prox 3/4 urethra) should exceed Pves
90
what is the abrams griffiths number on AG nomogram
Pdet at Q max
91
eq for bladder outlet obstruction index
BOOI = PdetQmax - 2*Qmax
92
BOOI interpretation
> 40 is obstructed, < 20 unobstructed
93
eq for bladder contractility index
PdetQmax + 5*Qmax
94
what BCI is nl
100-150= nl
95
what does BCI tell you
bladder strength
96
who needs UDS - 5
1. < 45 yo and failed meds, 2. no relief after TURP, 3. hx neurologic disease. 4. sx out of proportion to flow rate, 5. low-nl flow rate and high PVR
97
nomograms and women
nomograms only apply to men
98
common causes of obstruction in women
1. iatrogenic after SUI surgery, 2. dysfunctional voiding, 3. pelvic prolapse
99
uds caveat in women with obstruction
flouro is important to locate site of obstruction
100
first step in voiding
relaxation of striated sphincter
101
steps in voiding - 4
1. striated sphincter relaxation, 2. detrussor contraction, 3. vesical neck opening, 4. urine flow
102
compliance in BOO and TURP
reduced compliance may improve after turp
103
BOOI and women
cant be used b/c will grossly underestimate BOO as women void at much lower pressure
104
involuntary detrussor contraction and EMG
EMG signal may increase due to guarding reflex
105
DESD problem
can lead to impaired compliance and lead to upper tract deterioration.
106
mgmt of DESD - 2
if learned - can be unlearned. if not learned, requires bypassing nl voiding with CIC or sphincterotomy
107
situations where video uds would be useful - 3
1. eval bladder neck (internal sphincter), 2. neuro diseases w/ assd VUR, 3. female BOO
108
uds findings requiring intervention - 6
1. impaired compliance, 2. DESD, 3. DISD, 4. high pressure DO present throughout filling, 5. elevated DLPP (>40 cm H2O), 6. poor emptying with high pressure storage
109
characteristics of DO
1. involuntary detrussor contraction seen on UDS 2. assd w sx urgency/UUI, 3. can be provoked by cough/valsalva, 4. not same as OAB which describes a sx
110
What is PVR?
the volume of urine left in the bladder at the completion of micturition
111
What is uroflowmetry?
the measurement of the rate of urine flow over time
112
What is electromyography?
the electronic potentials produced by the depolarization of muscle membranes. In most UDS tests, EMG measurement of the striated sphincteric muscles of the perineum is done to evaluate possible abnormalities of perineal muscle function that are often associated with lower urinary tract symptoms and dysfunction.
113
What are pressure flow studies?
measure the relationship between pressure in the bladder and urine flow rate during bladder emptying.
114
What are videourodynamic studies?
include the addition of simultaneous imaging (usually fluoroscopy) during cystometry and/or PFS.
115
What is abdominal/valsalva leak point pressure?
measurement of urethral function or outlet competence and is the intravesical pressure at which urine leakage occurs due to increased abdominal pressure in the absence of a detrusor contraction.
116
What is a urethral pressure profile?
Continuous measurement of the fluid pressure needed to just open a closed urethra.
117
What is maximum urethral closure pressure?
the maximum difference between the urethral pressure and the intravesical pressure.
118
What parameters are most important for evaluating stress urinary incontinence?
CLPP
VLPP/ALPP
MUCP
PVR
119
Indications for UDS?
SUI considering surgery
Urgency considering intervention
Suspected NGB
LUTS considering intervention
120
Patient suspected of SUI does not demonstrate this on initial test. What should be tried next?
The urethral catheter should be removed. 50% will show SUI after catheter is removed.
121
A women with POP is undergoing UDS for SUI. What should be done first?
The prolapse should be reduced.
122
A patient has urgency incontinence after a procedure for SUI. What is the next step?
UDS to evaluate PFS looking for signs of bladder outlet obstruction.
123
A patient with urge incontinence does not illustrate DO on their UDS. What is the next step?
The patient should be counseled that this does not exclude DO as the cause.
124
What should evaluation of a neurogenic bladder include?
```
PVR
CMG
PFS
VUDS
EMG
```
125
What should be evaluated in patients with LUTS?
```
PVR
Uroflow
Filling cystometry
PFS
VUDS
```
126
Explain detrusor overactivity (DO) and its key characteristics.
DO is an involuntary detrusor contraction during bladder filling, associated with urgency and frequency. It can be neurogenic or idiopathic, and UDS may show phasic or terminal contractions.
127
How do you calculate BOOI, and what does it signify?
BOOI is calculated as
Pdet at Qmax
−
2
×
(
Qmax
)
Pdet at Qmax−2×(Qmax). >40 suggests obstruction, 20–40 equivocal, <20 unobstructed. It helps in diagnosing bladder outlet obstruction.
128
What is the Abrams-Griffiths Nomogram, and how does it work?
: It's a graphical tool used to diagnose bladder outlet obstruction in men by plotting detrusor pressure against urine flow rate. It distinguishes between obstruction, equivocal obstruction, or non-obstruction.
129
Describe the diagnosis and treatment of pelvic floor dysfunction.
Diagnosed through UDS, showing increased EMG activity during voiding, and a closed bladder neck. Treatment may include pelvic floor physical therapy, biofeedback, and relaxation techniques.
130
Explain detrusor underactivity (DU) and how it is diagnosed.
DU is characterized by weak or prolonged bladder contractions, resulting in poor emptying. Diagnosed through UDS with Pdet at Qmax <40 cm H2O and decreased uroflowmetry.
131
DU is characterized by weak or prolonged bladder contractions, resulting in poor emptying. Diagnosed through UDS with Pdet at Qmax <40 cm H2O and decreased uroflowmetry.
DU is characterized by weak or prolonged bladder contractions, resulting in poor emptying. Diagnosed through UDS with Pdet at Qmax <40 cm H2O and decreased uroflowmetry.
132
Explain the management and surveillance of neurogenic lower urinary tract dysfunction.
Includes CIC, medical therapy, onabotulinumtoxin A, and surveillance UDS in high-risk patients. Surveillance UDS is crucial for monitoring upper tract deterioration and assessing treatment effectiveness.
133
Describe the management options for BOO.
Depending on etiology (e.g., BPH), treatment can include alpha-blockers, surgical interventions like prostatic urethral lift, or other procedures to relieve obstruction.
134
BOO (Bladder neck)
135
BOO
136
DO
137
DSD
138
DU
139
female MUI
140
impaired compliance
141
male mui
142
normal uds
143
pelvic floor dysfunction
144
145
What should you do to make the diagnosis of urodynamic stress incontinence?
Clinicians who are making the diagnosis of urodynamic stress incontinence should assess urethral function.
146
If you are considering invasive therapy in patient with stress urinary incontinence, what basic test should you do in the office?
Surgeons considering invasive therapy in patients with SUI should assess post- void residual (PVR) urine volume.
147
When is urodynamics indicated for stress incontinence?
Clinicians may perform multi-channel urodynamics in patients with both symptoms and physical findings of stress incontinence who are considering invasive, potentially morbid or irreversible treatments.
148
If you cannot demonstrate stress incontinence with the urethral catheter in place during urodynamics, what is the next step?
Clinicians should perform repeat stress testing with the urethral catheter removed in patients suspected of having SUI who do not demonstrate this finding with the catheter in place during urodynamic testing.
149
When should urodynamics be performed in patients with pelvic organ prolapse?
How should this be done?
Clinicians should perform stress testing with reduction of the prolapse in women with high grade pelvic organ prolapse (POP) but without the symptom of SUI.
Multi-channel urodynamics with prolapse reduction may be used to assess for occult stress incontinence and detrusor dysfunction in these women with associated LUTS.
-- HIGH GRADE POP without SUI
-- REDUCE prolapse
-- Look for occult stress incontinence and detrusor dysfunction
150
What are the indications for urodynamics in patients with OAB?
Clinicians may perform multi-channel filling cystometry when it is important to determine if:
--Altered compliance
--Detrusor overactivity
--Or other urodynamic abnormalities are present (or not) in patients with urgency incontinence in whom invasive, potentially morbid or irreversible treatments are considered.
May perform pressure flow studies (PFS) in patients with urgency incontinence after bladder outlet procedures to evaluate for bladder outlet obstruction.
151
What are the indications for urodynamics in patients with urge urinary incontinence?
Clinicians may perform multi-channel filling cystometry when it is important to determine if:
--Altered compliance
--Detrusor overactivity
--Or other urodynamic abnormalities are present (or not) in patients with urgency incontinence in whom invasive, potentially morbid or irreversible treatments are considered.
May perform pressure flow studies (PFS) in patients with urgency incontinence after bladder outlet procedures to evaluate for bladder outlet obstruction.
152
What are the indications for urodynamics in mixed incontinence?
Clinicians may perform multi-channel filling cystometry when it is important to determine if:
--Altered compliance
--Detrusor overactivity
--Or other urodynamic abnormalities are present (or not) in patients with urgency incontinence in whom invasive, potentially morbid or irreversible treatments are considered.
May perform pressure flow studies (PFS) in patients with urgency incontinence after bladder outlet procedures to evaluate for bladder outlet obstruction.
153
In a patient with clinically suspected detrusor overactivity but no DO on urodynamics, what should the patient be told?
Clinicians should counsel patients with urgency incontinence and mixed incontinence that the absence of detrusor overactivity (DO) on a single urodynamic study does not exclude it as a causative agent for their symptoms.
154
When evaluating a patient with neurogenic bladder (including spinal cord injury and myelominingocele), what should a clinician obtain?
--PVR
--CMG
--Pressure Flow Analysis
--Videourodynamics (may)
--EMG in combination with CMG with or without PFS
Clinicians should perform *PVR assessment,* either as part of a complete urodynamic study or separately, during the initial urological evaluation of patients with relevant neurological conditions (e.g., spinal cord injury and myelomeningocele) and as part of ongoing follow-up when appropriate.
Clinicians should perform a *complex cystometrogram (CMG)* during initial urological evaluation of patients with relevant neurological conditions with or without symptoms and as part of ongoing follow-up when appropriate. In patients with other neurological diseases, physicians may consider CMG as an option in the urological evaluation of patients with LUTS.
Clinicians should perform *pressure flow analysis* during the initial urological evaluation of patients with relevant neurological conditions with or without symptoms and as part of ongoing follow-up when appropriate, in patients with other neurologic disease and elevated PVR or in patients with persistent symptoms.
When available, clinicians may perform *fluoroscopy at the time of urodynamics (videourodynamics)* in patients with relevant neurologic disease at risk for neurogenic bladder, in patients with other neurologic disease and elevated PVR or in patients with urinary symptoms.
Clinicians should perform *electromyography (EMG)* in combination with CMG with or without PFS in patients with relevant neurologic disease at risk for neurogenic bladder, in patients with other neurologic disease and elevated PVR or in patients with urinary symptoms.
155
Should a physician perform a PVR in patient with LUTS?
Clinicians may perform PVR in patients with LUTS as a safety measure to rule out significant urinary retention
both initially and during follow up.
156
Should clinicians perform a uroflow in patients with LUTS?
Uroflow may be used by clinicians in the initial and ongoing evaluation of male patients with LUTS when an
abnormality of voiding/emptying is suggested.
157
Should clinicians perform urodynamics in patients with DO and LUTS?
Clinicians may perform multi-channel filling cystometry when it is important to determine if DO or other abnormalities of bladder filling/urine storage are present in patients with LUTS, particularly when invasive, potentially morbid or irreversible treatments are considered.
158
Should clinicians perform pressure flow studies in men with LUTS?
Clinicians should perform PFS in men when it is important to determine if *urodynamic obstruction* is present in men with LUTS, particularly when invasive, potentially morbid or irreversible treatments are considered.
159
Should clinicians perform pressure flow studies in women?
Clinicians may perform PFS in women when it is important to determine if obstruction is present.
160
When should clinicians perform videourodynamics?
Guideline 12: When available, clinicians may perform fluoroscopy at the time of urodynamics (videourodynamics) in patients with relevant neurologic disease at risk for neurogenic bladder, in patients with other neurologic disease and elevated PVR or in patients with urinary symptoms.
Guideline 19: Clinicians may perform videourodynamics in properly selected patients to localize the level of obstruction, particularly for the diagnosis of primary bladder neck obstruction.
161
What are the signs of autonomic dysreflexia?
Flushing, sweating above the level of the injury, headache, severe hypertension and reflex bradycardia that can ultimately be lethal due to intracranial hemorrhage if not recognized or treated appropriately
Treat with draining bladder or stopping the insult causing AD and nitropaste
Generally limited to persons with SCI (T6 level and above)
162
A 50-year-old male patient presents with symptoms of urgency and nocturia. During the urodynamic study, the urologist is most likely to evaluate which of the following parameters during the filling/storage phase?
Multiple-Choice Options:
A. Pves and Pdet
B. MUPP
C. FLUORO
D. EMG
Correct Answer:
A. Pves and Pdet
In-depth Explanation for All Answer Choices:
A. Pves and Pdet: Correct. During the filling/storage phase, Pves (Total bladder pressure) and Pdet (Detrusor pressure) are commonly measured using a filling cystometrogram (FCMG). These metrics are essential for understanding the patient's symptoms and choosing appropriate treatment.
B. MUPP: Incorrect. Micturitional Urethral Pressure Profilometry (MUPP) is relevant during the emptying phase of micturition, not the filling/storage phase.
C. FLUORO: Incorrect. Fluoroscopy of the outlet during the filling/storage phase is indicated but is more pertinent to outlet evaluation rather than the bladder function alone.
D. EMG: Incorrect. Electromyography of periurethral striated musculature (EMG) is not generally a primary parameter evaluated during the filling/storage phase.
Memory Tool:
Remember "Fill, Pressure, Storage" for FCMG involving Pves and Pdet during the filling/storage phase.
Reference Citation:
Table 111.1, Urodynamics Simplified - Filling/storage phase section
Rationale for Information:
This question is important because it tests the urologist's understanding of the parameters to be evaluated during the filling/storage phase of a urodynamic study, which is crucial for patient diagnosis and treatment.
163
Clinical Vignette:
A 65-year-old woman is being evaluated for difficulty in voiding. What parameters are typically evaluated during the emptying phase in a urodynamic study?
Multiple-Choice Options:
A. Pves and Pdet
B. RU
C. FLUORO and EMG
D. Flowmetry and Residual urine
Correct Answer:
D. Flowmetry and Residual urine
In-depth Explanation for All Answer Choices:
A. Pves and Pdet: Incorrect. These are key parameters during the filling/storage phase, not specifically during the emptying phase.
B. RU: Incorrect. Residual urine (RU) is important but is not the only parameter evaluated during the emptying phase.
C. FLUORO and EMG: Incorrect. These parameters provide important data but are not the primary parameters evaluated during the emptying phase.
D. Flowmetry and Residual urine: Correct. During the emptying phase, uroflow (Flowmetry) and residual urine (RU) integrate the activity of the bladder and the outlet, offering the most comprehensive data for evaluation.
Memory Tool:
Remember "Empty, Flow, Residual" to recall Flowmetry and Residual urine during the emptying phase.
Reference Citation:
Table 111.1, Urodynamics Simplified - Emptying phase section
Rationale for Information:
The question is vital for ensuring that the urologist knows what parameters to look at when diagnosing issues related to voiding, as errors can affect patient management.
164
A 45-year-old female comes to your clinic with complaints of urinary incontinence when she coughs or sneezes. What test is used to measure leak point pressures?
Multiple-Choice Options:
A. DLPP
B. FLUORO
C. VLPP
D. EMG
Correct Answer:
C. VLPP
In-depth Explanation for All Answer Choices:
A. DLPP: Incorrect. Detrusor Leak Point Pressure (DLPP) is more relevant for spontaneous leakage and isn't typically used to assess leakage due to physical stress like coughing or sneezing.
B. FLUORO: Incorrect. Fluoroscopy is an imaging technique but isn't specific for measuring leak point pressures during stress events like coughing or sneezing.
C. VLPP: Correct. Valsalva Leak Point Pressure (VLPP) is the measurement used to evaluate leak point pressures during increased abdominal pressure, such as coughing or sneezing.
D. EMG: Incorrect. Electromyography (EMG) assesses periurethral striated musculature and is not directly used to measure leak point pressures.
Memory Tool:
For Valsalva or cough-induced leaks, think "Valsalva Leak Point Pressure" or "Very Likely Physical Pressure".
Reference Citation:
Table 111.1, Urodynamics Simplified - Filling/storage phase, parameter VLPP
Rationale for Information:
Understanding the appropriate tests for different types of incontinence is critical for patient management and ensures targeted interventions.
165
Clinical Vignette:
A 40-year-old male patient is being evaluated for difficulty in emptying his bladder completely. Which of the following tests would be useful in visualizing the outlet during the emptying phase?
Multiple-Choice Options:
A. FCMG
B. UPP
C. FLUORO
D. MUPP
Correct Answer:
C. FLUORO
In-depth Explanation for All Answer Choices:
A. FCMG: Incorrect. Filling Cystometrogram (FCMG) is generally used to assess the bladder during the filling/storage phase.
B. UPP: Incorrect. Urethral Pressure Profilometry (UPP) evaluates urethral pressure but doesn't provide visualization of the outlet.
C. FLUORO: Correct. Fluoroscopy of the outlet during the emptying phase helps in visualizing and understanding outlet behavior.
D. MUPP: Incorrect. Micturitional Urethral Pressure Profilometry (MUPP) is used to evaluate urethral pressure during micturition but does not visualize the outlet.
Memory Tool:
Think "FLUORO Flows Freely" to remember that FLUORO visualizes the outlet during the emptying phase.
Reference Citation:
Table 111.1, Urodynamics Simplified - Emptying phase section, parameter FLUORO
Rationale for Information:
Correctly identifying the most appropriate imaging test for the emptying phase aids in precise diagnosis and effective treatment.
166
Clinical Vignette:
A 60-year-old man is experiencing urinary incontinence post-prostatectomy. Which test measures urethral pressure?
Multiple-Choice Options:
A. MUPP
B. RU
C. FCMG
D. EMG
Correct Answer:
A. MUPP
In-depth Explanation for All Answer Choices:
A. MUPP: Correct. Micturitional Urethral Pressure Profilometry (MUPP) is specifically designed to measure urethral pressure during the emptying phase, providing insights into the post-prostatectomy status.
B. RU: Incorrect. Residual urine (RU) measures the amount of urine left in the bladder after voiding but does not directly measure urethral pressure.
C. FCMG: Incorrect. Filling Cystometrogram (FCMG) focuses on bladder pressures during the filling/storage phase and is not specifically for urethral pressure measurement.
D. EMG: Incorrect. Electromyography (EMG) measures electrical activity in the periurethral striated musculature but does not measure urethral pressure.
Memory Tool:
To remember that MUPP measures urethral pressure, think "MUPP Measures Urethral Pressure Precisely."
Reference Citation:
Table 111.1, Urodynamics Simplified - Emptying phase section, parameter MUPP
Rationale for Information:
Understanding urethral pressure measurements is crucial in the management of post-prostatectomy incontinence, making this an important question for evaluation.
167
Clinical Vignette:
A 35-year-old woman comes in complaining of intermittent urinary incontinence. She has tried pelvic floor exercises without much success. Which test would be best for evaluating the periurethral striated musculature?
Multiple-Choice Options:
A. EMG
B. FLUORO
C. FCMG
D. RU
Correct Answer:
A. EMG
In-depth Explanation for All Answer Choices:
A. EMG: Correct. Electromyography (EMG) is used to assess the periurethral striated musculature and can provide important information on the effectiveness of pelvic floor exercises.
B. FLUORO: Incorrect. Fluoroscopy is more relevant for visualizing the bladder outlet during the emptying phase.
C. FCMG: Incorrect. Filling Cystometrogram (FCMG) focuses primarily on bladder pressures during the filling/storage phase.
D. RU: Incorrect. Residual urine measures the amount of urine left after voiding but does not evaluate periurethral musculature.
Memory Tool:
Think "EMG Examines Muscles" to remember that EMG is used for evaluating periurethral striated musculature.
Reference Citation:
Table 111.1, Urodynamics Simplified - Emptying phase section, parameter EMG
Rationale for Information:
This question is essential to understand the correct modality for evaluating the periurethral striated musculature, especially when pelvic floor exercises have been ineffective.
168
Clinical Vignette: A 68-year-old male recently suffered a cerebrovascular accident and is now experiencing urinary issues. You suspect voiding dysfunction related to his neurological disease. What pattern of voiding dysfunction is most commonly seen in patients with cerebrovascular accidents?
Multiple-Choice Options:
A. Overactive Detrusor, Normal Compliance, Synergic Smooth Sphincter, Synergic Striated Sphincter
B. Overactive Detrusor, Decreased Compliance, Dyssynergic Smooth Sphincter, Synergic Striated Sphincter
C. Areflexia Detrusor, Normal Compliance, Competent but Nonrelaxing Smooth Sphincter, Fixed Tone Striated Sphincter
D. Impaired Detrusor, Increased Compliance, Open Smooth Sphincter, Dyssynergic Striated Sphincter
orrect Answer: A
In-Depth Explanation:
A: This is the most common pattern seen in cerebrovascular accident patients: Overactive detrusor, normal compliance, and both smooth and striated sphincters are synergic (Table 116.1, Row 1).
B, C, D: These are not the typical voiding dysfunction patterns for cerebrovascular accidents.
Memory Tool: CVA is "A-OK" (A option is OK) to help remember that in CVA, the detrusor is overactive but everything else is normal or synergic.
Specific Reference Citation: Table 116.1
Rationale: Knowing the typical voiding dysfunctions related to specific neurological conditions can guide treatment options and patient expectations.
169
Clinical Vignette: A 72-year-old female with a long history of Parkinson's Disease is presenting with urinary urgency and frequency. What is the characteristic voiding dysfunction in Parkinson’s Disease?
Multiple-Choice Options:
A. Overactive Detrusor, Normal Compliance, Dyssynergic Smooth Sphincter, Dyssynergic Striated Sphincter
B. Overactive Detrusor, Impaired Compliance, Normal Smooth Sphincter, Synergic Striated Sphincter
C. Areflexia Detrusor, Decreased Compliance, Synergic Smooth Sphincter, Fixed Tone Striated Sphincter
D. Impaired Detrusor, Normal Compliance, Open Smooth Sphincter, Synergic Striated Sphincter
Correct Answer: B
In-Depth Explanation:
A: While detrusor overactivity is correct, the compliance is not normal, and the sphincters are not dyssynergic in Parkinson's disease (Table 116.1, Row 5).
B: This is the characteristic pattern for Parkinson’s Disease: Overactive detrusor, impaired compliance, and normal smooth sphincter. The striated sphincter is synergic.
C, D: These options do not accurately represent voiding dysfunction in Parkinson’s Disease.
Memory Tool: Think "B for Bradykinesia" in Parkinson’s, to help remember the impaired compliance alongside detrusor overactivity.
Specific Reference Citation: Table 116.1
Rationale: Recognizing how Parkinson's disease affects voiding can guide therapeutic approaches, improving patient quality of life.
170
Clinical Vignette: A 50-year-old male with Type 2 diabetes reports difficulty with urination. What pattern of voiding dysfunction is usually seen in diabetic patients?
Multiple-Choice Options:
A. Areflexia Detrusor, Increased Compliance, Synergic Smooth Sphincter, Fixed Tone Striated Sphincter
B. Overactive Detrusor, Normal Compliance, Open Smooth Sphincter, Dyssynergic Striated Sphincter
C. Impaired Detrusor, Areflexia, Overactive Smooth Sphincter, Normal Striated Sphincter
D. Impaired Detrusor, Areflexia, Overactive Smooth Sphincter, Synergic Striated Sphincter
Correct Answer: D
In-Depth Explanation:
A, B, C: These do not accurately reflect the typical voiding dysfunction pattern in diabetes (Table 116.1, Last Row).
D: The characteristic pattern in diabetes includes an impaired detrusor and areflexia, with an overactive smooth sphincter and synergic striated sphincter.
Memory Tool: "D for Diabetes" helps you remember the option D is correct for Diabetes.
Specific Reference Citation: Table 116.1
Rationale: Diabetes affects multiple body systems, including urinary function. Understanding the voiding dysfunction can guide management and improve symptom control.
171
Clinical Vignette: A 55-year-old male is diagnosed with Multiple System Atrophy and is experiencing urinary incontinence. What is the characteristic voiding dysfunction in Multiple System Atrophy?
Multiple-Choice Options:
A. Overactive Detrusor, Impaired Compliance, Open Smooth Sphincter, Synergic Striated Sphincter
B. Overactive Detrusor, Impaired Compliance, Non-Relaxing Smooth Sphincter, Synergic Striated Sphincter
C. Areflexia Detrusor, Normal Compliance, Synergic Smooth Sphincter, Dyssynergic Striated Sphincter
D. Overactive Detrusor, Impaired Compliance, Open Smooth Sphincter, Striated Sphincter Exhibits Denervation
Correct Answer: D
In-Depth Explanation:
A, B, C: These options do not fully represent the voiding dysfunction in Multiple System Atrophy as per Table 116.1.
D: The correct pattern includes an overactive detrusor, impaired compliance, open smooth sphincter, and the striated sphincter may show evidence of denervation.
Memory Tool: Think "D for Denervation," to help remember that striated sphincter exhibits denervation in Multiple System Atrophy.
Specific Reference Citation: Table 116.1
Rationale: Understanding the urologic manifestations of Multiple System Atrophy can be pivotal in symptom management and improves patient outcomes.
172
Clinical Vignette: A 32-year-old male who suffered a spinal cord injury at T6 level reports difficulty in voiding. What pattern of voiding dysfunction should you expect?
Multiple-Choice Options:
A. Overactive Detrusor, Normal Compliance, Synergic Smooth Sphincter, Dyssynergic Striated Sphincter
B. Areflexia Detrusor, Decreased Compliance, Open Smooth Sphincter, Fixed Tone Striated Sphincter
C. Overactive Detrusor, Normal Compliance, Dyssynergic Smooth Sphincter, Synergic Striated Sphincter
D. Areflexia Detrusor, Normal Compliance, Open Smooth Sphincter, Synergic Striated Sphincter
Correct Answer: A
In-Depth Explanation:
A: This matches the pattern in suprasacral spinal cord injury: overactive detrusor, normal compliance, and the smooth sphincter is synergic but the striated sphincter may be dyssynergic if the lesion is above T7 (Table 116.1).
B, C, D: These options do not match the pattern commonly seen in suprasacral spinal cord injury.
Memory Tool: For spinal cord injury above T7, think "A for Above" to remember that the answer is A.
Specific Reference Citation: Table 116.1
Rationale: Recognizing the typical pattern of voiding dysfunction in spinal cord injuries allows for targeted interventions to manage symptoms effectively.
173
Clinical Vignette: A 5-year-old boy has myelodysplasia and his parents report that he has been having frequent urinary tract infections. What pattern of voiding dysfunction is commonly seen in Myelodysplasia?
Multiple-Choice Options:
A. Areflexia Detrusor, Normal Compliance, Open Smooth Sphincter, Striated Sphincter Shows Some Evidence of Denervation
B. Overactive Detrusor, Impaired Compliance, Synergic Smooth Sphincter, Fixed Tone Striated Sphincter
C. Impaired Detrusor, Normal Compliance, Dyssynergic Smooth Sphincter, Dyssynergic Striated Sphincter
D. Areflexia Detrusor, Normal Compliance, Open Smooth Sphincter, Fixed Tone Striated Sphincter
Correct Answer: A
In-Depth Explanation:
A: The typical pattern for Myelodysplasia is areflexia detrusor, normal compliance, and open smooth sphincter. The striated sphincter commonly shows some evidence of denervation (Table 116.1).
B, C, D: These options are not consistent with the pattern seen in Myelodysplasia.
Memory Tool: Remember "A for Areflexia" to keep in mind the detrusor behavior in Myelodysplasia.
Specific Reference Citation: Table 116.1
Rationale: Knowledge of voiding dysfunction in Myelodysplasia can inform treatment decisions and help prevent complications like urinary tract infections.
174
Clinical Vignette: A 60-year-old woman with a history of tabes and pernicious anemia comes to your office with difficulty urinating. What would be the typical voiding dysfunction seen in patients with tabes and pernicious anemia?
Multiple-Choice Options:
A. Overactive Detrusor, Impaired Compliance, Synergic Smooth Sphincter, Dyssynergic Striated Sphincter
B. Areflexia Detrusor, Normal Compliance, Synergic Smooth Sphincter, Fixed Tone Striated Sphincter
C. Impaired Detrusor, Increased Compliance, Synergic Smooth Sphincter, Loss of Sensation
D. Impaired Detrusor, Increased Compliance, Synergic Smooth Sphincter, Striated Sphincter Exhibits Denervation
Correct Answer: C
In-Depth Explanation:
A, B, D: These options do not accurately describe the voiding dysfunction observed in tabes and pernicious anemia.
C: According to Table 116.1, the typical voiding dysfunction includes impaired detrusor activity, increased compliance, and synergic smooth sphincter. The primary problem in these patients is loss of sensation.
Memory Tool: "C for Sensation Ceased" helps to remember that the primary issue is the loss of sensation.
Specific Reference Citation: Table 116.1
Rationale: Understanding the voiding dysfunctions related to tabes and pernicious anemia can aid in targeted treatment, particularly given that the primary issue is loss of sensation.
175
Clinical Vignette: A 45-year-old male who recently had a diskectomy presents with urinary symptoms. What pattern of voiding dysfunction is most likely?
Multiple-Choice Options:
A. Areflexia Detrusor, Normal Compliance, Competent Non-Relaxing Smooth Sphincter, Striated Sphincter Shows Evidence of Denervation
B. Overactive Detrusor, Impaired Compliance, Dyssynergic Smooth Sphincter, Dyssynergic Striated Sphincter
C. Impaired Detrusor, Increased Compliance, Synergic Smooth Sphincter, Fixed Tone Striated Sphincter
D. Areflexia Detrusor, Normal Compliance, Competent Non-Relaxing Smooth Sphincter, Synergic Striated Sphincter
Correct Answer: A
In-Depth Explanation:
A: Matches the pattern from Table 116.1 for Disk Disease: Areflexia detrusor, normal compliance, competent non-relaxing smooth sphincter, and evidence of denervation in the striated sphincter.
B, C, D: These options are not consistent with the pattern seen in Disk Disease.
Memory Tool: Remember "A for Areflexia and After diskectomy" to associate with disk disease.
Specific Reference Citation: Table 116.1
Rationale: Understanding the typical voiding dysfunction post-diskectomy can lead to more effective management and potentially quicker recovery.
176
Clinical Vignette: A 50-year-old female patient with Type 2 Diabetes complains of urinary incontinence. What is the typical pattern of voiding dysfunction in diabetes?
Multiple-Choice Options:
A. Impaired Detrusor, Increased Compliance, Open Smooth Sphincter, Synergic Striated Sphincter
B. Impaired Detrusor, Increased Compliance, Open Smooth Sphincter, Striated Sphincter Exhibits Denervation
C. Impaired Detrusor, Increased Compliance, Open Smooth Sphincter, Striated Sphincter Shows Evidence of Motor Neuropathy
D. Overactive Detrusor, Normal Compliance, Dyssynergic Smooth Sphincter, Fixed Tone Striated Sphincter
Correct Answer: C
In-Depth Explanation:
A, B, D: These choices do not align with the typical diabetes-induced voiding dysfunction.
C: Table 116.1 describes impaired detrusor, increased compliance, and open smooth sphincter in diabetes. Striated sphincter shows evidence of motor neuropathy.
Memory Tool: Think "C for Carbs cause Complications" to remember the impact of diabetes.
Specific Reference Citation: Table 116.1
Rationale: Recognizing how diabetes can affect urinary function is crucial for overall disease management and symptom alleviation.
177
178
Detrusor contraction is mediated by the ___ nervous system
parasympathetic S2- S4
179
Detrusor relaxation is mediated by the ___ nervous system
sympathetic (T10-L2)
180
In the CNS, ___ controls the external sphincter
Onuf's nucleus
181
In the CNS, ___ coordinates detrusor contraction & external sphincter relaxation
Pontine Micturition Center
182
Pdet = ___ - ____
Pves - Pabd
183
Detrusor leak point pressure > ___ cmH20 puts increased risk of upper tract deterioration
40
184
EMG on UDS measures ____ activity
external sphincter
185
Spinning top urethra is a sign of _____
dysfunctional voiding
186
Cerebral cortex lesion
___ bladder
___ sphincter
____ detrusor-sphincter coordination
overactive bladder
normal sphincter
normal detrusor-sphincter coordination
*loss of frontal cortex inhibition of pontine micturition center*
187
Suprasacral SC lesion
___ bladder
___ sphincter
____ detrusor-sphincter coordination
overactive bladder
spastic sphincter
DSD - no detrusor-sphincter coordination
188
Autonomic dysreflexia occurs with spinal cord lesions above ___
T6
189
Autonomic dysreflexia
___ BP
___ HR
High BP
Low HR
Hypertension & bradycardia
190
Sacral SC / PNS lesion
___ bladder
___ sphincter
____ detrusor-sphincter coordination
acontractile bladder
flaccid sphincter
no coordination (both flaccid)
