Urodynamics (Aquick Pocket Guide)

Giancarlo 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

Partially 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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Preface
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.
In 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.
Despite 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.
Urodynamics 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
Special 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
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
4 Urodynamic Testing: When and Which. . . . . . . . . . . 49

4.1 When Is Urodynamic Testing Indicated? . . . . . 49
4.2 Which Testing Should Be Selected? . . . . . . . . . 50
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
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
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
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
xii Contents
8.2 DSD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

8.3 Fowler Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . 137
8.4 Dysfunctional Voiding. . . . . . . . . . . . . . . . . . . . . 138
8.5 Sphincter Bradykinesia in Parkinson’s
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
9 Urethral Profilometry . . . . . . . . . . . . . . . . . . . . . . . . . 143

9.1 Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
9.2 Method of Measurement . . . . . . . . . . . . . . . . . . 144
9.3 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
9.4 Reading the Curve . . . . . . . . . . . . . . . . . . . . . . . 146
9.5 Morphology of the Curve. . . . . . . . . . . . . . . . . . 148
9.6 Normal Urethral Pressure Values . . . . . . . . . . . 149
9.7 The Clinical Role of Rest Urethral
Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . . . . 151
9.8 Stress Urethral Pressure Profile . . . . . . . . . . . . 151
10 Videourodynamics (VUDS) . . . . . . . . . . . . . . . . . . . . 155

10.1 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
10.2 Indications for the Addition of Video
to Conventional Urodynamics . . . . . . . . . . . . . 158
10.2.1 Tailoring VUDS for Neurogenic
Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . 159
10.2.2 Female Urinary Incontinence . . . . . . . . 162
10.2.3 Bladder Outlet Obstruction
in Women . . . . . . . . . . . . . . . . . . . . . . . . . 164
10.2.4 Primary Bladder Neck
Obstruction in Young Male . . . . . . . . . . 164
10.3 Disadvantages of Fluoroscopy. . . . . . . . . . . . . . 166
10.4 Critical Reappraisal of Videourodynamics . . . 166
11 Ambulatory Urodynamics . . . . . . . . . . . . . . . . . . . . . 169

11.1 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
11.2 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
11.3 Clinical Relevance of AUM . . . . . . . . . . . . . . . . 173
Contents xiii
12 Urodynamics of the Upper Urinary Tract . . . . . . . . 175

12.1 Physiology of Urine Transport. . . . . . . . . . . . . . 176
12.2 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
12.2.1 Diuretic Renography &
Diuretic IVP . . . . . . . . . . . . . . . . . . . . . . 178
12.2.2 Doppler Sonography . . . . . . . . . . . . . . . 179
12.2.3 Pressure-Flow Study
(Whitaker Test) . . . . . . . . . . . . . . . . . . . . 180
Further Reading of Urodynamics . . . . . . . . . . . . . . . . . . 185
Appendix A: Urodynamic Testing Consent

Form – Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Abbreviations
ACC Anterior cingulate cortex

ACOG American College of Obstetricians and
Gynecologists
ALARA As low as reasonably achievable
ALPP Abdominal leak-point pressure
AUA American Urological Association
AUASS AUA Symptom Score
AUGS American Urogynecologic Society
AUM Ambulatory urodynamics monitoring
BNO Bladder neck obstruction
BOO Bladder outlet obstruction
CMG Cystometrogram
DESD Detrusor external sphincter dyssinergia
DLPP Detrusor leak-point pressure
DWT Detrusor wall thickness
EMG Electromyography
FWC Free water clearance
ICI International Consultation on Incontinence
ICIQ-UI International Consultation on Incontinence
Questionnaire – Urinary Incontinence
ICS International Continence Society
IMPS Inferior margin pubis symphysis
IPSS International Prostate Symptom Score
LUT Lower urinary tract
LUTS Lower urinary tract symptoms
MCC Mid-cingulate cortex
MUCP Maximal urethral closing pressure
MVV Maximum voided volume
xvi Abbreviations
NBCi Nocturnal bladder capacity index

Ni Nocturia index
NICE National Institute of Clinical Excellence
NPi Nocturnal polyuria index
NUV Nocturnal urinary volume
OAB Overactive bladder
Pabd Abdominal pressure
PAG Periaqueductal gray
Pdet Detrusor pressure
PFC Prefrontal cortex
PMC Pontine micturition center
PNV Predicted number of nightly voids
Pura Urethral pressure
Pves Vesical pressure
PVR Post-void residual
Qmax Peak urine flow
SMA Supplementary motor area
UDI-SF Urogenital Distress Inventory – Short Form
UDS Urodynamics
UPP Urethral pressure profile
US Ultrasound
VCU Videocystourethrography
Chapter 1
The Framework of Basic
Science
1.1 What Is Urodynamics?
Urodynamics is the study of the function of the lower urinary

tract, e.g., bladder and urethra. More precisely it analyzes the
urinary stream during voiding and pressures in the bladder
and abdomen both during micturitions and in the periods
between them. For these features, urodynamics disclose pecu-
liarities that neither radiology nor endoscopy is able to
process.
As in other high-technology testing procedures (e.g., elec-
trocardiography, electroencephalography), urodynamic test
have greatest clinical validity when their interpretation is left
to the treating physician, who should either supervise the
study or be responsible for correlating all the findings with
personal clinical observations.
1.2 The Micturition Cycle

The function of the bladder is relatively straightforward:
store urine to about 400–500 ml in adults and then empty
voluntarily in consequence of the stimulus of voiding.
These two events, storage and emptying, are known as
micturition cycle (Fig. 1.1).
G. Vignoli, Urodynamics, 1
DOI 10.1007/978-3-319-33760-9_1,
2 Chapter 1. The Framework of Basic Science
Micturition cycle
Filling Re-filling
Voiding
Q
Pves
Pabd
Pdet
EMG
Bladder
volume
Figure 1.1 The micturition cycle. As the bladder fills, relaxation of

detrusor muscle allows low-pressure storage of urine. Concurrently,
a crescendo increase of EMG activity maintains continence by
enhancing urethral resistance. Voiding is a voluntary act associated
with a lowering of urethral resistance by sphincter relaxation fol-
lowed by a coordinated contraction of detrusor muscle which leads
to complete emptying of the stored urine
Typically the bladder empties seven times a day and, usu-

ally, never at night.
The normal micturition last approximately 15–20 s.
While urine storage and evacuation are equally important
to bladder health, it is actually the storage of urine the event
more significant during everyday life.
The bladder is an organ at low pressure. That means that
during the filling, its pressure does not exceed 10 cmH20. This
condition allows the continuous gravitational flow of urine
from the ureter to the bladder. When, for pathological rea-
sons, the pressure in the bladder exceeds 40 cmH20, urine
flow stops and accumulates in the ureters, causing along the
time their dilatation.
1.2 The Micturition Cycle 3
One third of bladder filling takes place without the indi-

vidual sense in it. Later on, the need to urinate becomes
progressively more urgent.
The normal subject can overcome the stimulus by con-
tracting voluntarily the external sphincter and by predispos-
ing himself to search a bathroom to fulfill the function of
emptying the bladder.
In the toilet, emptying begins with the voluntary relax-
ation of the external sphincter followed by the contraction of
the detrusor muscle.
Storage and voiding involves complex interactions between
the bladder, urethral sphincter, and nervous system. Urethral
sphincter properly depends upon two elements:
• The smooth muscle sphincter
• The voluntary striated sphincter
In general, urinary storage is a function of the sympathetic
nervous system, whereas micturition is a function of the para-
sympathetic nervous system. The somatic nervous system is
responsible for the control of the external urinary sphincter,
allowing for volitional control of the bladder function.
The basic process of micturition cycle and peripheral ner-
vous pathways involved can be summarized as follow: (Fig. 1.2)
• Storage of urine (detrusor relaxation and internal sphinc-
ter contraction) is under sympathetic control via impulses
transmitted through the hypogastric nerve originating in
the spinal cord at the level of T10–L2.
• Voluntary onset of voiding is under control of the somatic
nervous system, through the pudendal nerve originating in
the spinal cord at the level of S1–S4. Pudendal nerve is
responsible for the voluntary relaxation of the external
urinary sphincter (which is part of striated pelvic floor
muscles).
• Emptying of the bladder (detrusor contraction and smooth
sphincter relaxation) is under parasympathetic control
through the pelvic nerve originating in the spinal cord at
the level of S1–S4.
T10
L1
Parasympathetic Inferior L2
efferent nerves mesenteric
ganglion
S2
S3
Afferent A-delta Sympathetic
S4 fibers efferent nerves
Hypogastric S2
nerves
Pelvic S3
nerves
S4
β2 – receptor z
M2 – receptor
Somatic efferent
Bladder nerves
b1 – receptor
Bladder
neck
Pudendal
External nerves
sphincter
Figure 1.2 Afferent and efferent nervous pathways of the bladder.

The function of the lower urinary tract is under the control of sev-
eral neurologic pathways. The sympathetic nervous system allows
for bladder relaxation and internal sphincter contraction. This is
mediated through the hypogastric nerve, and these signals originate
from the spinal cord at levels T10–L2. The parasympathetic system
allows for bladder contraction and internal sphincter relaxation.
This is mediated through the pelvic nerve, and these signals origi-
nate from the spinal cord levels at S2–S4. The somatic (voluntary)
system allows for the control of the external sphincter. This is medi-
ated through the pudendal nerve, and these signals originate from
the motoneurons (Onuf’s nucleus) of the spinal cord at S2–S4 level.
Bladder sensation travels along the myelinated A-delta fibers in the
hypogastric, pelvic, and pudendal nerves
1.3 The Brain 5
All these nerves are lower motor neurons and are under
the control of inputs from higher centers of central nervous
system.
• Bladder sensation is mediated by myelinated A-delta
fibers and travels in the pelvic nerve to the spinal cord. The
inputs are then relayed to the periaqueductal gray (PAG)
region in the pons (unsensed phase of storage) and then
through the insula to the brain (conscious phase of
storage).
1.3 The Brain

In adults the brain (Fig. 1.3) plays a key role in the control of
micturition events.
Until the age of three or four, voiding is an involuntary
reflex event mediated by a spinobulbospinal pathway pass-
ing through the pontine micturition center (PMC) in the
brainstem. When tension receptors in the bladder reach
threshold, that afferent information is transmitted to the
periaqueductal gray (PAG) in the midbrain where an excit-
atory signal is then relayed to the PMC. The PMC then sends
signal to the sacral spinal cord, causing excitation of para-
sympathetic pathways and inhibition of somatic and sympa-
thetic pathways that leads to relaxation of the urethral
sphincter, contraction the bladder, and consequent expulsion
of urine.
With increasing maturation of the nervous system, transi-
tion between the phases of storage and expulsion of urine
becomes voluntary, with evidence suggesting that the PAG
relays afferent information from the bladder via the hypo-
thalamus, thalamus, and insula to the anterior cingulate cor-
tex (ACC) and prefrontal cortex (PFC) activating a conscious
sensation of need of voiding. The PFC, usually involved in
attention and response selection processes, inhibits the PAG
so that excitatory signals to the PMC are suppressed, thereby
keeping the bladder in storage phase until the appropriate
moment to void has been determined.
Supplementary
motor area
5
Prefrontal
cortex 4
Anterior 3
cyngulate
gyrus
Insula
Periaqueductal 2
grey (PAG)
Afferent pathway
Pontine 7
1
micturition center
Efferent pathway
Figure 1.3 Brain control of micturition. Information on the intra-

vesical pressure is coveyed in the activity of thin myelinated
(A-delta) afferent fibers (1) and transmitted via spinothalamic tract
to the mesencephalic periaqueductal grey (PAG) (2), which in turn
relay to the insula where the sensations are mapped (3) Insula activ-
ity and resulting bladder sensation increases with bladder volume,
progressing from a first sensation of filling, to a first desire to void,
and then to a strong or even painful desire to void. Healthy adults
can postpone micturition despite a full bladder and can intention-
ally initiate voiding even if bladder is nearly empty. The cingulate
cortex (4) is involved in monitoring and evaluating bladder sensa-
tions, and may control micturition via its efferent connection to the
pre-frontal cortex (5) When voiding starts, pre-frontal cortex acti-
vate both supplementary motor area (SMA) (6) that control pelvic
floor muscles and the external sphincter via efferent projections to
sacral motor neurons (Onuf’s nucleus) and pontine micturition cen-
ter (PMC) (7)
Suggested Reading 7
Medial motor areas (SMA, M1) may govern directly the

activity of Onuf’s nucleus and consequently sphincter muscle
contractions via their efferent output to the sacral spinal cord.
Suggested Reading
de Groat WC, Yoshimura N (2015) Anatomy and physiology of
lower urinary tract. Handb Clin Neurol 130:61–101
de Groat WC, Griffiths D, Yoshimura N (2015) Neural control of the
lower urinary tract. Compr Physiol 5:327–396
Griffiths D (2015a) Neural control of micturition in human: a work-
ing model. Nat Rev Urol 12:695–705
Griffiths D (2015b) Functional imaging of structures involved in
neural control of the lower urinary tract. Handb Clin Neurol
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Griffiths D, Fowler CJ (2013) The micturition switch and its fore-
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Chapter 2
Key Symptoms Analysis
and Diagnostic Algorithms
There are several standardized validated questionnaire to aid

the clinician in evaluating lower urinary tract symptoms,
degree of bother, and quality of life including:
• Urogenital Distress Inventory Short Form (UDI-6)
• ICI Questionnaire Short Form on Urinary Incontinence
(ICIQ-UI)
• AUA Symptom Score (AUASS)
• International Prostate Severity Score (IPSS)
Validated questionnaires are helpful in structuring history
taking and providing checklists for gathering data.
However, the proper interpretation of urodynamics starts
from the knowledge of the mechanisms beyond the symptoms
of the lower urinary tract since UDS study should be custom-
ized for each individual to maximize the utility of the test.
In other words, when you run a test, from simple uroflow-
metry to more complex multichannel pressure/flow study,
you should have exactly in mind what you are looking for. A
precise algorithm should enable you to navigate easily among
the patient’s symptoms reducing unnecessary testing and
accelerating the diagnostic process.
The key symptoms of lower urinary tract are divided
according to micturition cycle in:
• Storage symptoms
• Voiding symptoms
DOI 10.1007/978-3-319-33760-9_2,
10 Chapter 2. Key Symptoms Analysis
2.1 Storage Symptoms

Storage symptoms include:
• Increased daytime frequency
• Urgency
• Nocturia
• Urinary incontinence
• Nocturnal enuresis in children
• Painful bladder
2.2 Increased Daytime Frequency

Increased daytime frequency is the need to void too often by
day.
The normal diurnal frequency is between three and seven
times a day.
Increased frequency is seldom the patient’s only complaint. It is
usually associated with other symptoms, most frequently urgency.
Frequency can occur as a result of reduced functional
bladder capacity or incomplete bladder emptying or both. In
addition, it may be caused by anxiety or by patient (mostly
females) adaptation to avoid urine leakage by maintaining a
relatively low urinary volume in the bladder (coping mecha-
nism). Also a fear of urinary retention, especially in older
males, may be compensated by a frequent voiding.
The assessment of functional bladder capacity through a
voiding diary is the first step in the evaluation of symptom.
Box 2.1: Definition of Bladder Capacity
Bladder capacity may be defined in three contexts:

• Functional bladder capacity
• Cystometric bladder capacity
• Anatomic bladder capacity
2.2 Increased Daytime Frequency 11
Functional bladder capacity is defined as the volume

of urine accumulated in the bladder prior to voluntary
micturition; it is typically evaluated by measuring the
maximum, mean, or median voided volume (MVV)
recorded on a bladder diary. Functional bladder capac-
ity is about 300 ml in females, 400 ml in males, and
120 ml in children. Its value tends to be smaller than
cystometric capacity.
Cystometric capacity is defined as the intravesical
volume at the end of the filling of CMG, when the
patient experiences a strong desire to void or is granted
to micturate by the examiner. Usually its value is higher
than functional bladder capacity.
Anatomic bladder capacity or maximum anesthetic
bladder capacity is defined as the volume that can be
infused into the bladder during a cystoscopic procedure
while the patient is under anesthesia. This maneuver
can be used to evaluate bladder wall compliance in spe-
cific clinical conditions (painful bladder, actinic cystitis).
Since it is measured under spinal or general anesthesia,
it tends to be significantly greater than both functional
and cystometric capacity.
If functional bladder capacity is normal, increased fre-

quency is a consequence of an increased output of urine. This
condition may depend on:
• Increased intake of fluid (occasionally psychotic)
• Osmotic diuresis (diabetes mellitus)
• Excessive production of antidiuretic hormone (diabetes
insipidus)
If functional bladder capacity is reduced, frequency may
be related to:
• Detrusor dysfunction (OAB, reduced compliance, hyper-
sensitive bladder)
• Voiding dysfunction with post-void residual urine
Free flowmetry with assessment of post-void residual urine

may be a reasonable approach to exclude a voiding problem.
Filling cystometry remains the most suitable test to evalu-
ate a detrusor dysfunction.
Conventional urodynamics may be necessary in some
cases (e.g., interrupted flow curve) to highlight a detrusor
underactivity or a dysfunctional voiding.
For increased daytime frequency simplified algorithm, see
Fig. 2.1.
2.3 Urgency
Urgency is the complaint of a sudden, compelling desire to
void which is difficult to defer.
Box 2.2
In literature the terms urge and urgency are often

interchanged.
Urge is a strong desire of voiding in physiological
conditions.
Urgency is a pathological compelling desire of
voiding beyond full-bladder capacity that is
perceived as a negative sensory experience (see
Chap. 7).
Although urgency is the distinctive feature of overactive

bladder (OAB), it remains imprecisely characterized and
incompletely understood with respect to underlying patho-
physiology. There are at least three key components in what
the patient perceives as urinary urgency:
• Peripheral factors that generate the sensation of urgency
(first of all detrusor overactivity but also abnormal blad-
der sensation and inflammation)
2.3 Urgency 13
Increased daytime frequency
Urinanalysis & culture Voiding diary

Cytology
US post-void residual
Normal bladder Reduced bladder capacity
capacity
Det. dysfunction Bladder outlet

Increased fluid intake OAB obstruction
Diabetes mellitus
Diabetes insipidus Free flowmetry
Drugs (diuretics)
normal obstructed
filling cystometry multichannel UDS
Figure 2.1 Simplified algorithm of increased daytime frequency
• The processes by which the sensation is transmitted to the

brain (A-delta myelinated fibers or C fibers)
Bladder sensation is normally carried out by A-delta
myelinated fibers. In pathologic conditions (i.e., spinal
cord injury, inflammation, obstruction), C fibers are
recruited to form new synaptic connections. The result
is a lower threshold of micturition reflex.
• The manner in which the brain interprets and controls the
sensation.
In normal conditions, with near-empty bladder, the situa-
tion during much of the daily life, the cortical areas
which modulate the perception of urge are not detect-
ably activated, but activation in the midbrain of periaq-
ueductal gray area (PAG) indicates an unconscious
monitoring of ascending bladder signals.
At full-bladder capacity, strong voiding sensation is accom-
panied by an activation of the right insula, dorsal anterior
cingulate cortex, and supplementary motor area and by a
deactivation of the frontal cortex, which seems responsi-
ble of symptom control. In patients with OAB, weaker
insula activity is typically observed at low volumes and
stronger activity at high volumes, suggesting a sudden

and dramatic sensation of urgency. In addition, a reduced
deactivation of frontal cortex is typically seen.
In elderly the lost of control is a consequence of white
matter damage which may disrupt the connecting
pathways of the brain-bladder control network
decreasing ability to postpone voiding and increasing
urgency.
There is no consensus about the best way to measure this
symptom. Some clinicians prefer the voiding diary; others
support the use of scales used to assess pain. None of the two
methods take into account the compelling desire to void, i.e.,
the reduction in warning time that precedes the need to void.
In patient complaining urgency, infection and urological
malignancy should be ruled out.
Historically, urodynamics has not been recommended in
the initial evaluation of OAB, since it is defined primarily by
clinical symptoms. As the pathophysiology of the OAB has
become more clearly elucidated, UDS has again gained an
important role since it can provide objective data to reflect
these new findings.
Filling cystometry is the most suitable urodynamic test to
assess urgency.
Three findings can be observed:
• Phasic detrusor overactivity
• Terminal detrusor overactivity
• Hypersensitive bladder (see Chap. 7)
For urgency simplified algorithm, see Fig. 2.2.
Urgency
Voiding diary ? Pain scales ?
Filling cystometry
Urinanalysis &
culture
Cytology Phasic detrusor Terminal detrusor Hypersensitive
overactivity overactivity bladder
Post-void residual
In women, assessment of
estrogen status
Figure 2.2 Simplified algorithm of urgency

2.4 Nocturia 15
2.4 Nocturia
Nocturia is the complaint of interruption of sleep one or more
times because of the need to micturate. Each void is preceded
and followed by sleep.
Normal subject does not get up in the night to urinate.
However over 65 years for men and 75 for women, it is nor-
mal to get up once a night.
Historically nocturia has been considered as a secondary
consequence of an underlying urological disease, i.e., BPH or
detrusor overactivity.
In fact, nocturia can be related to four distinct mechanisms:
• An overall increase of urine production (global polyuria)
• An increase in urine production only at night (nocturnal
polyuria)
• Reduced bladder capacity
• Sleep disorder
The term global polyuria indicates an overall urine volume
greater than 40 ml/kg in adults. It is usually seen in individu-
als with diabetes mellitus, diabetes insipidus, primary poly-
dipsia, voluntary excessive fluid intake, hypercalcemia, or
intake of particular drugs (mostly diuretics).
Nocturnal polyuria is defined by the ICS as a nocturnal
urine volume (NUV) greater than 20–33 % of total 24-h urine
volume. This proportion is called nocturnal polyuria index
(NPi) and its value varies from 14 % in young adults to 34 %
in people over 65 years.
Nocturnal polyuria is one of the most frequent causes of
nocturia in adults, especially in elderly age group. Nocturnal
polyuria occurs in consequence of several factors including:
• Modification of the circadian rhythm of production of
arginine vasopressin (AVP) hormone (water diuresis)
• Excess production of atrial natriuretic peptide occurring in
chronic heart failure with nighttime evacuation of daytime
fluid sequestration with peripheral edema (solute diuresis)
• A combination of both
Water diuresis is represented by high FWC and low osmo-
larity at night. For solute diuresis the driving force seems to
be increased sodium clearance at night.
Nocturnal polyuria can also occur in consequence of sleep

apnea which may produce an excess of atrial natriuretic pep-
tide and medications (diuretics).
Reduced bladder capacity includes all the conditions associ-
ated with storage symptoms, in particular overactive bladder
and bladder outlet obstruction. Nocturia occurs when the noc-
turnal bladder capacity (NBC) is overcome by the amount of
urine entering the bladder during the night. Hence, even with-
out exceeding production of urine at night, the bladder cannot
assume the NUV storage. This concept is expressed by the NBC
index (NBCi), which corresponds to the actual number of voids
minus the predicted number of voids. The predicted number of
voids is obtained by subtracting one from Ni. Hence, NBCi >0
means that voids at night occur below the maximum single
voided volume at day (MVV), indicating that the bladder itself
cannot store the amount of urine produced at night.
Even insomnia can cause nocturia in the elderly.
This classification facilitates appropriate treatment; it is,
therefore, essential to conduct a complete and structured
assessment of the symptom to avoid subsequent failures.
Box 2.3: Terminology of Nocturia Based on Voiding Diary
NUV (nocturnal urinary volume) = the amount of

urine passed at night including the first voided
volume in the morning.
Ni (nocturia index) = nocturnal urine volume/maxi-
mum single voided volume.
NPi (nocturnal polyuria index) nocturnal urine
volume/24-h urine volume. It should be <1.
MVV (maximum voided volume) = maximum single
voided volume during the day.
PNV (predicted number of nightly voids) = nocturia
index-1.
NBCi (nocturnal bladder capacity index) = actual
number of nocturnal voids – predicted number of
nocturnal voids.
2.5 Urinary Incontinence 17
For nocturia simplified algorithm, see Fig. 2.3.
2.5 Urinary Incontinence

Urinary incontinence is the complaint of any involuntary
leakage of urine.
There are three main types of incontinence:
1. Stress incontinence
2. Urge incontinence
3. Mixed incontinence
2.5.1 Stress Incontinence
Stress incontinence is the complaint of involuntary loss of

urine on effort or physical exertion, e.g., sporting activities, or
on coughing or sneezing. It can be defined also as an “activity-
related incontinence” to avoid confusion with psychological
stress.
In female, there are two mechanisms underlying the
disorder:
1. Defect in the urethral support for a weakening of the mus-

cles of the floor pelvic or ligament injury support (hyper-
mobility of the urethra).
2. Lack of urethral tone (intrinsic sphincter deficiency).
In most of the women, the mechanisms coexist.
The primary aim of clinical assessment is to distinguish

between:
• Uncomplicated SUI
• Complicated SUI
Urodynamic testing is not necessary when conservative
treatment is planned and even before anti-incontinence
18
Nocturia
Voiding diary
Chapter 2.
24-h polyuria Reduced bladder capacity Nocturnal polyuria Sleep disorder “Patient awake before the
desire to pass urine”
Overactive bladder Chronic heart failure

Diabetes mellitus
Bladder outlet obstruction Inappropiate AVP secretion
Diabetes insipidus
Excessive fuid intake
Key Symptoms Analysis
Uroflowmetry & PVR Urine osmolarity day & night

Cystometry Na excretion
In case
Pressure/flow study
Figure 2.3 Simplified algorithm of nocturia

surgery (mid-urethral sling) in presence of uncomplicated

SUI.
According to ACOG guidelines, the minimum evaluation
to distinguish between uncomplicated and complicated SUI
includes:
• History
• Urinalysis
• Physical examination
• Demonstration of stress incontinence
• Assessment of urethral mobility
• Measurement of post-void residual urine
History
Box 2.4: Urinary Incontinence Questionnaires
Urogenital Distress Inventory (UDI)

Incontinence Impact Questionnaire (IIQ)
Questionnaire for Urinary Incontinence Diagnosis
(QUID)
Incontinence-Quality of Life Questionnaire (I-QoL)
Incontinence Severity Index (ISI)
International Consultation on Incontinence
Questionnaire (ICIQ)
There are several validated urinary incontinence question-

naires (see Box 2.4).
The history should include questions about the type of
incontinence (e.g., stress, urge, mixed), precipitating events,
frequency of occurrence, severity, pad use, and effect of symp-
toms on activities of daily living.
Uncomplicated SUI can be presumed from the following

findings:
• Loss of urine associated with physical effort (coughing,
sneezing, etc.)
• Absence of recurrent UTI
• Absence of irritative or voiding symptoms
• No prior surgery
• Absence of medical conditions that can affect lower uri-
nary tract (neurological disease, diabetes)
Urinalysis
Urinary tract infection should be ruled out through urinalysis

and urine culture.
Physical Examination
All pelvic support compartments (anterior, posterior, apical)

should be assessed (see POP-Q).
If no pelvic organ prolapse (POP) is found beyond the
hymen, then the patient’s SUI remains uncomplicated.
Conversely, evidence of POP beyond the hymen is consistent
with complicated SUI because prolapse can reduce or mask
the severity of symptoms (the so-called occult incontinence)
and impair the bladder emptying by producing a relative
obstruction of the urethra.
Demonstration of Stress Incontinence: Cough

Stress Test
Visualization of urine loss from the urethra simultaneous with a

cough is diagnostic of SUI. Delayed fluid loss is considered a
negative cough stress test result and suggests cough-induced
detrusor overactivity. The cough stress test can be performed
with the patient in the supine position during the physical
examination. However, if urine leakage is not observed, the
cough stress test needs to be repeated with the patient standing
and with a full bladder (or a minimum bladder volume of

300 mL) to maximize test sensitivity. If no leakage is observed
despite patient symptoms of SUI, conventional urodynamic test-
ing and, in case, ambulatory urodynamics are recommended.
Assessment of Urethral Mobility
Urethral hypermobility is defined as a 30° or greater displace-

ment from the horizontal when the patient is in a supine
lithotomy position and straining. The presence of urethral
hypermobility indicates uncomplicated SUI. Lack of urethral
mobility is associated with a significant increase in the failure
rate of anti-incontinence surgery. The cotton swab test has
been the traditional assessment of urethral hypermobility
(see Q-tip test).
Post-void Residual Urine
The presence of an elevated post-void residual urine volume

(>150 ml) can indicate a bladder-emptying abnormality due
to a mechanical obstruction secondary to pelvic organ
prolapse.
An elevated post-void residual urine volume in the
absence of POP is uncommon and should trigger an evalua-
tion of the bladder-emptying mechanism, usually with a
pressure-flow urodynamic study.
The Role of Urodynamic Investigation in Complicated

SUI
The role of urodynamic investigation in complicated SUI can

be addressed separately to detrusor function (cystometry),
urethral function (urethral profilometry at rest and under
stress), and voiding process (uroflowmetry) or to the whole
micturition cycle (conventional urodynamics with leak point
pressure assessment).
Conventional urodynamics emphasizes:

• The leakage of urine simultaneous with increased abdomi-
nal pressure in absence of a detrusor contraction (urody-
namic stress incontinence)
• Detrusor overactivity (OAB)
In addition, it can assess the efficiency of the sphincteric
mechanism through:
• VLPP >60 cm H2O during the filling phase of cystometry
• MUCP >20 cm H2O during urethral profilometry at rest
Videourodynamics is recommended for the evaluation of
bladder outlet obstruction after incontinence surgery. In
doubtful cases ambulatory urodynamics may be necessary to
identify the underlying causes of the disorder.
For female stress incontinence simplified algorithm, see
Fig. 2.4.
Female stress urinary incontinence
History
Stress vs. urge questionnaires
Physical examination
Cough test
Urethral Hypermobility
POP-Q
Urinanalysis & culture
US post-void residual
Uncomplicated SUI Complicated SUI
Conservative treatment Multichannel UDS

Sling surgery
Figure 2.4 Simplified algorithm of stress incontinence in female

Male Stress Incontinence
Male stress incontinence is a common problem in subjects who

have been treated for prostate cancer. The symptom is typically
caused by a damage of the external sphincter. Less commonly it
can be due to a detrusor dysfunction or to an obstruction result-
ing from an anastomotic stricture. In general, there is a good
prognosis for the return of continence within 6 months–1 year
after surgery. During this period in which pelvic floor muscle
exercises are recommended, clinical evaluation should be lim-
ited to voiding diary and pad testing to supervise the functional
bladder capacity and the progress in the severity of inconti-
nence. A post-void residual urine by ultrasound may be useful to
exclude a stricture of the anastomosis. The best timing for uro-
dynamics is at 1 year from surgery. When conventional urody-
namics is performed in incontinent patient after radical
prostatectomy, a significant number of men will not demonstrate
urodynamic stress incontinence due to the obstructive effect of
the urethral catheter. For the same reason, ALPP may be signifi-
cantly higher and Qmax significantly lower than real values.
Unintubated urodynamics, utilizing only the rectal catheter
for the measurement of the abdominal pressure, is probably the
preferred approach in post-prostatectomy incontinent patients.
Videourodynamics may improve detection sensitivity of
slight incontinence allowing the visualization of small volumes
of contrast into the bulbous urethra. Urethral profilometry may
help in the assessment of sphincter weakness since there is a
correlation between functional urethral length and maximum
urethral closure pressure with the severity of incontinence.
For male stress incontinence simplified algorithm,
see Fig. 2.5.
Male stress urinary incontinence
Pad testing
US post-void residual First six months-one year
Unintubated conventional UDS Urethroscopy
Figure 2.5 Simplified algorithm of stress incontinence in male

2.5.2 Urge Incontinence
Urge incontinence is the complaint of involuntary leakage

associated or immediately preceded by urgency. Although
stress incontinence is the most common type of urinary
incontinence in middle-aged women, urge incontinence is
the most common form of urinary incontinence in older
women.
The aging process affects the structure and function of
supraspinal neural networks necessary for control of bladder
function and continence. In particular with aging, there is a
progressive decline of the dorsolateral PFC function with an
increased difficulty in cognitive performance in response to
environmental contingencies, like voluntary control of
micturition.
Urge incontinence is a symptom-based diagnosis and may
or may not be caused by detrusor overactivity which is a
urodynamic observation characterized by involuntary detru-
sor contraction during the filling phase.
The only current available tool to link urgency to bladder
is filling cystometry. However, patients with urgency do not
always present with detrusor overactivity. DO is detected in
only about half of the patients by conventional urodynamics.
Conversely, at least 50 % of patients presenting with DO on
urodynamics do not complain any urgency. This gap between
sensation and bladder activity may be indicative of different
clinical states not completely understood yet.
Another urodynamic finding, particularly in elderly peo-
ple, is terminal detrusor overactivity which is a single involun-
tary detrusor contraction occurring at cystometric capacity
resulting in bladder emptying. In these cases, the “warning
time,” i.e., the time elapsing between the strong stimulus of
voiding and the beginning of micturition, is typically reduced
in consequence of the aforementioned decline of brain-
bladder control.
Urine loss may be due, but not necessarily, to a poor func-
tioning sphincteric mechanism.
In practice, there are two subtypes of urgency:
• With leakage (OAB wet)

• Without leakage (OAB dry)
Although the overall prevalence of OAB is similar among
men and women, women are more likely to experience OAB
wet (55.0 % of women with OAB vs. 16.3 % of men) due to
different anatomical conditions.
Urge incontinence can be managed either conservatively
or with surgical intervention. Urodynamics does not seem to
have a pivotal role in this decision. It is generally agreed that
initial treatment should be conservative with a combination
of behavioral and drug therapies.
The role of surgery in the treatment of female mixed
incontinence is controversial because there is thought to be a
high failure rate, related in part to preexisting detrusor dys-
function. However, there is some evidence that surgery may
relieve symptoms of DO, especially if stress symptoms prevail
over urge symptoms.
In males, it is important to verify the simultaneous pres-
ence of bladder outlet obstruction.
2.5.3 Mixed Urinary Incontinence

Mixed urinary incontinence (MUI) is the involuntary loss of
urine associated with the sensation of urgency and also with
exertion, effort, sneezing, or coughing. The disorder is very
frequent (between 30 and 50 % of female with urinary symp-
toms have proved mixed urinary incontinence), but the
underlying cause is poorly understood. The main question,
still unresolved, concerns the interdependence or less of the
two conditions. Without a clear understanding of the patho-
physiological and anatomical changes associated with MUI,
treatment is often misdirected.
The traditional paradigm for treatment of MUI, based on
expert opinion, has been to focus initial treatment on the
predominant incontinence subtype.
Conventional urodynamics is recommended to get a com-
plete picture of the condition verifying the presence and/or
coexistence of detrusor overactivity, urodynamic stress incon-

tinence, and intrinsic sphincteric dysfunction, but often the
choice of therapy depends more on the clinical experience of
the specialist than from the data obtained from the
investigation.
2.6 Nocturnal Enuresis

Nocturnal enuresis is the complaint of loss of urine occurring
during sleep.
2.6.1 Terminology
• Primary: no prior period of sustained dryness

• Secondary: recurrence of nighttime wetting after 6 months
or longer of dryness
• Monosymptomatic: normal void occurring at night in bed
in the absence of any other symptoms referable to the
urogenital tract
• Polysymptomatic: bed-wetting associated with other blad-
der symptoms such as urgency
2.6.2 The Path to Becoming Dry
Most children become dry at night after achieving bowel

control, in the following sequence:
• Bowel control during sleep
• Bowel control when awake
• Dry in the day
• Dry at night after a variable interval from being dry during
the day (Stein and Susser 1967)
7.5 % of children are dry at night by the age of 2 years;
57 % by the age of three and 81 % by the age of four.
2.6 Nocturnal Enuresis 27
Children are not considered enuretic until they have

reached 5 years of age. Furthermore for the diagnosis of noc-
turnal enuresis to be established, a child 5–6 years old should
have two or more bed-wetting episodes per month, and a
child older than 6 years of age should have one or more wet-
ting episode per month. About 90 % of children with bed-
wetting have primary enuresis; that is, they have never been
dry for a significant period. A smaller proportion (10 %) have
secondary onset of enuresis, i.e., they start bed-wetting after
6–12 months or more of being dry.
The disorder is multifactorial, but according to the current
methods of treatment, three basic mechanisms can be
recognized:
• Nocturnal polyuria as a result of low nocturnal vasopres-

sin levels – The hormone arginine vasopressin is naturally
produced in a circadian rhythm by the hypothalamus and
stored in the pituitary gland. Its function is to increase
the reabsorption of water in the kidneys. Normally, there
is a higher release of arginine vasopressin at night com-
pared to that during the day, resulting in a reduction in
the volume of urine produced during sleep. In some chil-
dren, this circadian rhythm has not yet developed, and
the amount of urine produced exceeds the bladder’s
natural capacity.
• Bladder overactivity/low voided volume – Overactive
bladder contractions may occur while the bladder is filling
and result in wetting before it is full. The child’s natural
voided volume may also be relatively low. Both may be
associated with symptoms of urgency and signs of fre-
quency in the day, but not always with daytime wetting.
• Lack of arousal from sleep – This is due to difficulty in
responding to the sensation of a full bladder and waking
up and/or “holding on” at night.
Children wetting the bed may have a problem either with
nocturnal polyuria or bladder overactivity or a combination
of both. However, all have problems with arousal from sleep.
The role of urodynamics in enuretic children is limited to

polysymptomatic enuresis in order to exclude:
• Overactive bladder
Children with OAB may display holding maneuvers,
such as standing on tiptoes, crossing of the legs, or squat-
ting with the heel pressed into the perineum.
• Dysfunctional voiding
Dysfunctional voiding symptoms vary from mild day-
time frequency and post-void dribbling to daytime and
nighttime wetting, urgency, urge incontinence, pelvic hold-
ing maneuvers, and urinary tract infections (UTIs). In the
most severe form, children with dysfunctional voiding
resemble those with neurogenic bladder or bladder outlet
obstruction due to posterior urethral valves.
• Underactive bladder
The condition is diagnosed if a child voids three or
fewer times in 24 h or if he or she does not void for 12 h.
These children may also use abdominal straining to void.
Multichannel urodynamic testing is unnecessary and usu-
ally is limited to selected cases.
Noninvasive uroflowmetry, commonly in conjunction with
pelvic floor electromyography and post-void residual urine
quantification by bladder ultrasonography or scanning, is a
useful noninvasive tool in evaluating children for lower uri-
nary tract dysfunction.
For nocturnal enuresis simplified algorithm, see Fig. 2.6.
2.7 Giggle Incontinence

Giggle incontinence is the occurrence of involuntary, complete
bladder evacuation induced by laughter. It typically appears in
children aged 5–7 years but may occur at older ages. The child’s
voiding pattern is otherwise normal. Giggle incontinence
results from detrusor overactivity induced by laughter, and it
improves with effective treatment of detrusor overactivity.
2.8 Painful Bladder 29
Nocturnal enuresis
History
Focused neurologic examination

Urinalysis & culture
Monosymptomatic Polysymptomatic
Uroflowmetry & surface

EMG
Conventional UDS
Figure 2.6 Simplified algorithm of nocturnal enuresis
2.8 Painful Bladder

Painful bladder is the complaint of recurring discomfort or
pain in the bladder and the surrounding pelvic region. The
symptoms vary from case to case and even in the same indi-
vidual. People may experience mild discomfort, pressure,
tenderness, or intense pain in the bladder and pelvic area.
Symptoms may include an urgent need to urinate, a frequent
need to urinate, or a combination of these symptoms. Pain
may change in intensity as the bladder fills with urine or as it
empties. Women’s symptoms often get worse during men-
struation. They may sometimes experience pain during vagi-
nal intercourse. Assessment should rule out other treatable
conditions before considering a diagnosis of painful bladder.
The most common of these diseases in both sexes are urinary
tract infections and bladder cancer. In men, common diseases
include chronic prostatitis. In women, endometriosis is a com-
mon cause of pelvic pain.
Due to a lack of specific marker, the first step of diagnostic
algorithm should include:
• Urinalysis and urine culture
• Cytology and (when indicated) cystoscopy
The role of urodynamics remains inconclusive. The most

significant finding is that at filling cystometry, the volumes at
each interval (first desire, normal desire, strong desire) and
the volumes at maximum cystometric capacity are signifi-
cantly lower without any sign of detrusor overactivity (hyper-
sensitive bladder). Free flowmetry may be interrupted due to
pelvic floor muscle overactivity that frequently can be
observed in this condition. Likewise, maximal urethral pres-
sure and maximal urethral closure pressure show values sig-
nificantly higher than normal.
Pathognomonic for diagnosis, however, is bladder disten-
tion under anesthesia showing diffuse glomerulations present
in at least four quadrants of the bladder, with at least ten
lesions per quadrant.
For painful bladder simplified algorithm, see Fig. 2.7.
2.9 Voiding Symptoms

Voiding symptoms are abnormal sensations experienced dur-
ing voiding phase.
They include a number of specific complaints:
• Hesitancy (difficulty in initiating micturition)
• Straining (muscular effort used either to initiate, maintain,
or improve the voiding stream)
• Position-dependent micturition (complaint of having to
take specific positions to improve bladder emptying)
• Slow stream (perception of reduced urine flow)
Painful bladder
Urinanalysis & culture Urodynamics ? Bladder distention

Citology Glomerulations
If positive
Intermittent flow
Cytoscopy Hypersensitive bladder
Figure 2.7 Simplified algorithm of painful bladder

2.9 Voiding Symptoms 31
• Intermittent stream (urine flow which stops and starts dur-

ing micturition)
• Terminal dribble (prolonged final part of micturition when
the flow has slowed to a dribble)
• Dysuria (burning during micturition)
• Stranguria (difficult micturition)
• Need to immediately re-void (complaint that further mic-
turition is necessary soon after passing urine)
All these complaints have as a common final outcome the

poor emptying of the bladder.
Diagnostic algorithm is similar, but the causes behind the
complaint are different in men (adult and young) and in women.
2.9.1 Voiding Symptoms in Adult Men
Voiding symptoms in adult men may depend on three causes:

• Obstruction (more common)
• Detrusor hypocontractility (still poorly defined)
• Poor relaxation of the external sphincter (also called dys-
functional voiding)
Free flowmetry is the best screening test.
Free flowmetry may have a significant prognostic value
(see Chap. 6) avoiding unnecessary, invasive, pressure-flow
studies.
However, in cases of doubt and always before surgery or
other invasive procedures, a pressure/flow study is strongly
recommended.
2.9.2 Voiding Symptoms in Young Men
In young subjects, voiding symptoms may depend on a disease

of the bladder neck, also known as primary bladder neck
obstruction (PBNO) or, more frequently, by an inadequate
relaxation of the external sphincter (dysfunctional voiding). In
the latter case, the flowmetry is typically intermittent. The pres-
sure flow study with surface electromyography shows persis-

tence of the electromyographic signal in voiding phase (there is
no relaxation of the pelvic floor including external sphincter).
For voiding symptoms in men simplified algorithm, see
Fig. 2.8.
2.9.3 Voiding Symptoms in Women
Voiding symptoms in women may depend on four causes:

• Prolapse of 3rd–4th grade that compresses the urethra
• After anti-incontinence surgery
• Dysfunctional voiding (urethral syndrome)
• Detrusor hypocontractility
In a prolapse of 3rd–4th grade, the mechanism of dysuria
is intuitive. However, the compression urethra, as well as alter
bladder emptying, may mask a sphincter deficiency, which
can generate a de novo incontinence after surgery.
Footnote
In prolapse of 3rd–4th grade is an essential preliminary

maneuver to urodynamic investigation a manual reduc-
tion of the prolapse.
Voiding symptoms in men

Free flowmetry
Bell shaped Intermittent
Qmax predictive Dysfunctional voiding Det. hypocontractility

value (poor relaxing sphincter) (abdominal straining)
Multichannel UDS Multichannel UDS & EMG

If surgery planned
Figure 2.8 Simplified algorithm of voiding symptoms in men

2.9 Voiding Symptoms 33
The diagnosis of obstruction after anti-incontinence sur-

gery is made through a pressure/flow study better if associ-
ated with voiding cystography (videourodynamics) which
displays the level of the obstacle. The only record of pressures
may be ambiguous (see Chap. 7).
Dysfunctional voiding (in the past known as “urethral syn-
drome”) is a functional disorder identified by an incomplete
or absent external sphincter relaxation during voiding in
women without concomitant neurological problems.
A diagnosis of suspicion may be advanced, in a simplified
approach still quite common, with an intermittent free flow-
metry curve associated with a sensory urgency at filling cys-
tometry, and with an MUCP (maximum urethral closing
pressure) at rest higher than normal value (by age) of the
patient (see Chap. 9).
Clinical example
Female patient 42 years old with difficulty with micturi-
tion, occasional heartburn, and feeling of incomplete
bladder emptying. Dyspareunia. Occasional UTI
Flowmetry curve: intermittent
Qmax :17 ml/s
Post-void residual: 30 ml
Resting urethral pressure profile: MUCP: 98 cm H2O (n.v
by age: 68 cm H2O)
The definitive diagnosis can be made only by a pressure/
flow study associated with surface EMG of pelvic floor mus-
cles, which highlights the persistence of EMG activity during
voiding. Voiding is often associated with detrusor
hypocontractility.
Primary detrusor hypocontractility in women is a difficult
urodynamic diagnosis.
Qmax <12 ml/s and Pdet at Q max <20 cm H2O are refer-
ence values.
Some use the man voiding nomograms (ICS, Schaefer)
which rate detrusor contractility beside the degree of obstruc-
tion. The choice is inaccurate and questionable because the
woman void differently from the man (see Chap. 7).
Voiding symptoms in women

Free flowmetry
Bell shaped Intermittent
Obstruction or Det. Poorly relaxing sphincter

hypocontractility or Abdominal straining
Multichannel urodynamics
With EMG if suspected dyfunctional voiding
With fluoroscopy (videourodynamics) after incontinence surgery
Figure 2.9 Simplified algorithm of voiding symptoms in women
For voiding symptoms in women simplified algorithm, see

Fig. 2.9.
Suggested Reading
Abrams P, Cardozo L, Fall M et al (2002) The standardisation of ter-
minology of lower urinary tract function: report from the stan-
dardisation sub-committee of the International Continence
Society. Neurourol Urodyn 21:167–178
Anderson KM, Davis K, Flynn DJ (2015) Urinary incontinence and
pelvic organ prolapse. Med Clin North Am 99:405–416
Cervigni M, Natale F (2014) Gynecological disorders in bladder pain
syndrome/interstitial cystitis. Int J Urol 21(Supp1):85–88
Gormley EA, Lightner DJ, Faraday M et al (2015) Diagnosis and
treatment of overactive bladder (non-neurogenic) in adults
AUA/SUFU guidelines amendment. J Urol 193:1572–1580
Gratzke C, Bachmann A, Deascazeaud A et al (2015) EAU guide-
lines on the assessment of non-neurogenic male lower urinary
tract symptoms including benign prostatic obstruction. Eur Urol
67:1099–1109
Suggested Reading 35
Hanna-Mitchell AT, Kashyap M, Chan WV et al (2014)

Pathophysiology of overactive bladder and the success of treat-
ment: a systematic review from ICI-RS 2013. Neurourol Urodyn
33:611–617
Kuo TL, Ng LG, Chapple CR (2015) Pelvic floor spasm as a cause of
voiding dysfunction. Curr Opin Urol 25:311–316
Lenherr SM, Clemens JQ (2013) Urodynamics: with a focus on
appropriate indications. Urol Clin North Am 40:545–557
Mangera A, Chapple CR (2014) Application of guidelines to the
evaluation of the male patient with urgency and/or incontinence.
Curr Opin Urol 24:547–552
Marshall SD, Raskolnikov D, Blanker MH et al (2015) Nocturia: cur-
rent levels of evidence and recommendations from the
International Consultation on male lower urinary tract symp-
toms. Urology 85:1291–1299
Nygaard I (2004) Physiologic outcome measures for urinary inconti-
nence. Gastroenterology 126(Suppl1):S99–S105
Offiah I, McMahon SB, O’Reilly BA (2013) Interstitial cystitis/blad-
der pain syndrome diagnosis and management. Int Urogynecol
J 24:1243–1256
Panicker JN, Fowler CJ, Kessler TM (2015) Lower urinary tract dys-
function in neurological patient: clinical assessment and manage-
ment. Lancet Neurol 14:720–732
Stein Z, Susser M (1967) Social factors in the development of sphinc-
ter control. Dev Med Child Neurol 9:692–706
Weiss JP, Weinberg AC, Blaivas JC (2008) New aspects of the classi-
fication of nocturia. Curr Urol Rep 9:362–367
Wyndaele JJ, Vodusek DB (2015) Approach to the male patient with
lower urinary tract dysfunction. Handb Clin Neurol 130:143–164
Chapter 3
Physical Examination
and Laboratory Tests
Physical examination in general should evaluate mental sta-

tus, body mass index, mobility, physical dexterity, and abnor-
mal gait. More specifically, it should be addressed to lower
urinary tract and should be urodynamically oriented. A com-
plete examination should include assessment of the abdo-
men, vaginal examination in females, rectal examination in
males, and, in both sexes, focused neurological examination
of sacral dermatomes (S1–S4) which are strictly related to
lower tract function (Table 3.1).
3.1 Abdominal Palpation

Lower abdomen should be palpated and percussed to demon-
strate the bladder. In an adult, only a bladder containing 300 ml
is likely to be palpated or percussed above the symphysis pubis.
Sometimes the bladder may be difficult to palpate in spite of its
content (the so-called “floppy” bladder). In these cases, press-
ing on the suprapubic region and asking the patient if he feels
a need to void may be a good indication of a full bladder.
3.2 Vaginal Examination

Using a Sims vaginal speculum, anterior, posterior, and apical
compartment should be systematically assessed. The degree of
DOI 10.1007/978-3-319-33760-9_3,
38 Chapter 3. Physical Examination and Laboratory Tests
Table 3.1 Physical examination

General
Mental status
Body mass index (BMI)
Mobility
Physical dexterity
Abnormal gait
Abdominal palpation
Male Female
External genitalia Vaginal examination
Digital rectal examination Stress test for incontinence
Urethral hypermobility
Focused neurological examination

Perineal sensation
Voluntary squeeze
Reflex activity
PFM testing
pelvic prolapse should be evaluated trough the pelvic organ

prolapse quantification system (POP-Q). A cough test can be
performed to look for stress urinary incontinence. Q-tip test may
be used to assess urethral hypermobility.
Pelvic muscle tone and contraction strength should be
manually assessed.
3.2.1 POP-Q (Fig. 3.1)
Using the hymen as a fixed reference point, specific sites

are defined in the anterior, posterior, and apical vaginal
compartments and measured separately. These measure-
ments are then categorized into a structured staging system
(Fig. 3.2).
3.2 Vaginal Examination 39
Stage 0 = no prolapse (the apex can descend as far as 2 cm

relative to the total vaginal length)
Stage 1 = the most distal portion of the prolapse descends
to a point greater than 1 cm above the hymen
D
C
Ba Bp
Aa Ap
TVL
GH PB
Fig. 3.1 POP-Q exam. The pelvic organ prolapse quantification

(POP-Q) exam is used to quantify, describe, and stage pelvic sup-
port. There are six points measured at the vagina with respect to the
hymen. Points above the hymen are negative numbers; points below
the hymen are positive numbers. All measurements except TVL are
measured at maximum Valsalva
x
x
Stage 0
x
x
Stage 1
Hymenal
plane
Stage 2
Stage 3
Stage 4
Fig. 3.2 Pelvic prolapse staging. Various stages of prolapse in relation

to hymenal plane
Stage 2 = maximal extent of the prolapse is within 1 cm of

the hymen (outside or inside the vagina)
Stage 3 = prolapse extends more than 1 cm beyond the hymen
but not more than within 2 cm of the total vaginal length
Stage 4 = complete eversion or extension to within 2 cm of
the total vaginal length
The POP-Q staging system has been validated and demon-
strates good inter- and intra-observer reliability.
3.2.2 Q-Tip Test (Fig. 3.3)
The Q-tip test is an office test to evaluate the adequacy of

anatomic support of the bladder neck. A sterile, lubricated
“Q-tip” cotton bud is inserted into the urethra to the level of
bladder neck. The patient is then asked to strain. The rota-
tional movement of the bladder neck around the symphysis
3.2 Vaginal Examination 41
30˚
Fig. 3.3 Q-tip test determines the descent of the normal urethro-
vesical junction contributing to stress incontinence in women. More
than a 30° increase during exertional activities indicates a hypermo-
bile urethrovesical junction
pubis causes the Q-tip to move cranially. The angle of the

Q-tip is measured using an orthopedic goniometer at rest and
during straining The difference between the two angles is
calculated: a change of more than 30° is thought to represent
a hypermobile urethra.
The usefulness of the test, moderately annoying, is not shared
by all. In fact, the test is just an attempt to quantify numerically
an observation (mobility of the urethra) easily detected during
a physical examination. A “hypermobile urethra” is not neces-
sarily an urethra incontinent, but in a woman incontinent
hypermobility can be one of the mechanisms of the disorder.
3.3 Pelvic Floor Muscle (PFM) Testing

(Fig. 3.4)
Evaluation and measurement of pelvic floor muscle function
includes:
• An assessment of patient’s ability to contract and relax the
pelvic muscle selectively (i.e., squeezing without abdomi-
nal straining and vice versa)
• Measurement of the strength of contraction
Vaginal palpation is the technique currently used by most
physical therapists to evaluate a correct PFM contraction.
The technique consists of placing a finger in the distal one
third of the vagina and asking the woman to lift inward and
squeeze around the finger.
Muscle strength is measured through a modified Oxford
grading system.
Pelvic floor muscles testing
Fig. 3.4 PFM testing. One finger is placed in the distal one third of
the vagina, and the woman is asked to lift inward and squeeze
around the finger
3.5 Focused Neurological Examination 43
This is a six-point scale: 0 = no contraction, 1 = flicker, 2 = weak,

3 = moderate, 4 = good (with lift), and 5 = strong.
The technique is simple to use and does not require expen-
sive equipment (Table 3.2).
3.4 Rectal Examination

Rectal examination should exclude a fecal impaction, particu-
larly in the elderly, that could affect urodynamic measurements.
Prostate gland should be assessed for size, shape, consis-
tency, and abnormal tenderness.
3.5 Focused Neurological Examination

All patients should have a simple neurological examination
including a gross assessment of sensation and reflexes in
the legs.
Focused neurological examination is specifically addressed
to the dermatomes (S1–S4) directly involved in lower urinary
tract function (Fig. 3.5) and includes:
Perineal (“Saddle”) Sensation

A normal perineal sensation indicates that innervation of the
bladder, urethra, and rectum is intact.
Table 3.2 Pelvic floor 0 = Nil

assessment grading
1 = muscle on stretch-flicker
2 = weak squeeze with 2-s hold
3 = fair squeeze and 5-s hold with lift
4 = good squeeze and 7-s hold and
lift, repeat × 5
5 = strong squeeze and 10-s hold and
lift, repeat × 10
L3 L3
L1
S2 S2
S3
L2 S4 L2
S3
L3 S3 L1 L3
S2 S3 S2
S4
S3
S4
L2 L2
S5
Fig. 3.5 Dermatomes (S1–S4) directly involved in lower urinary

tract function
Anal Tone
The tone of the anal sphincter can be assessed when the examin-
ing finger passes into the anal canal. In peripheral nervous lesions
(i.e., myelomeningocele), the anal tone results clearly flaccid.
Voluntary Squeeze
Patient should be able to increase anal sphincter pressure by
voluntarily contracting the levator ani. In women unable to
3.5 Focused Neurological Examination 45
Fig. 3.6 Bulbocavernosus reflex. Digital squeezing of the glans penis

or clitoris induce a contraction in the anal sphincter
contract pubococcygeal muscles during vaginal examination,

voluntary contraction of the anal sphincter may be a valid
alternative in the functional assessment of the pelvic floor
muscles.
Sacral Reflex Activity

It includes two specific reflex responses:
• Anal reflex: stroking the perianal skin the anal sphincter
contracts.
• Bulbocavernosus reflex: digital squeezing of the glans
penis or clitoris induces a contraction in the anal sphincter
(Fig. 3.6).
As a result of neurological examination, patients can be

grossly grouped in four categories:
• Normal
• Lower motor neuron lesion, with absent sensation, decreased
muscle tone, and decreased reflexes
• Upper motor neuron lesion, with absent sensation, increased
muscle tone, increased reflexes, and upgoing Babinski mus-
cle spasms
• Mixed, with upper and lower motor neuron findings
3.6 Laboratory Evaluation

Laboratory evaluation should include:
• Checking for urinary tract infection
• Cytology to exclude urinary tract malignancy
• Biochemical tests for renal function (in selected cases)
Testing a specimen of urine with reagent strips for nitrites
and leucocytes can provide a reasonable screening tool in
urodynamic laboratory. If the patient has a urinary tract
infection, urodynamic testing should be postponed since this
could influence the findings. Urine specimen should be sent
for culture and any infection appropriately treated.
Cytology should be used in patient with new-onset urgency/
frequency without clear sign of infection in order to exclude
urinary tract malignancy.
Biochemical tests for renal function are recommended in
those cases at high risk of renal impairment (i.e., neurogenic
bladder patients, chronic urinary retention).
Suggested Reading
Haylen BT, Maher CF, Barber MD et al (2016) An International
Urogynecological Association (IUGA)/International Continence
Society (ICS) joint report on the terminology for female pelvic
organ prolapse (POP). Neurourol Urodyn 35:137–168
Bump RC (2014) The POP-Q system: Two decades of progress and

debate. Int Urogynecol J 25:441–3
Riss P, Dwyer PL (2014) The POP-Q Classification system: Looking
back and looking forward. Int Urogynecol J 25:439–40
Persu C, Chapple CR, Cauni V et al (2011) Pelvic Organ Prolapse
Quantification System (POP-Q) – a new era in pelvic prolapse
staging. J Med Life 4:75–81
Dumoulin C, Glazener C, Jenkinson D (2011) Determining the opti-
mal pelvic floor muscle training regimen for women with stress
urinary incontinence. Neurourol Urodyn 30:746–753
Podnar S, Vodusek DB (2015) Lower urinary tract dysfunction in
patients with peripheral nervous system lesions. Handb Clin
Neurol 130:203–224
Herbruck LF (2008) Stress urinary incontinence: an overview of
diagnosis and treatment options. Urol Nurs 28:186–198
Chapter 4
Urodynamic Testing: When
and Which
4.1 When Is Urodynamic Testing Indicated?
In the last few years, several societies (ICS, AUA, NICE,

AUGS, Urinary Incontinence Treatment Network) have pub-
lished recommendations regarding the use of urodynamics.
These guidelines can be summarized as follows:
Urodynamics may be optional or even unnecessary when:
• A conservative treatment is planned.
• In patients with uncomplicated stress urinary incontinence.
• In patients with neurogenic bladder at low risk of renal
complications (multiple sclerosis).
Urodynamics is useful when:
• The patient’s symptoms do not correlate with objective
findings (complex symptoms).
• Prior therapies have failed.
Urodynamics is strongly recommended:
• In females with urinary incontinence or pelvic organ pro-
lapse when an invasive procedure is planned
• In men with voiding symptoms to assess if symptoms are
due to bladder outlet obstruction or detrusor underactivity
when TURP is planned
• In patients with neurogenic bladder who will require long-
term urologic management to establish a baseline
DOI 10.1007/978-3-319-33760-9_4,
50 Chapter 4. Urodynamic Testing: When and Which
4.2 Which Testing Should Be Selected?
Urodynamics testing range in complexity and include:

• Noninvasive evaluation
• Invasive evaluation
In turn, invasive evaluation includes:
• Conventional urodynamics
• Ambulatory urodynamics
Some patients may not need the full spectrum of tests; in
fact, some patients may not require urodynamic testing at all
after the clinical evaluation is complete.
Table 4.1 indicates urodynamic testing currently available
and function investigated, and Table 4.2 indicates acronyms
of measured urodynamic parameters.
Each test has its own specific indications:
• Uroflowmetry in combination with assessment of bladder
emptying by catheterization or ultrasound is a simple non-
Table 4.1 List of urodynamic testing and function investigated

UDS testing Function investigated
Uroflowmetry Voiding process
Cystometry Storage phase
DLPP Risk of upper tract deterioration
VLPP Urethral competence
Pressure flow study Voiding process
Urethral pressure profile Urethral function
EMG Pelvic floor muscle activity
Videourodynamics Anatomical and functional details
Ambulatory urodynamics Micturition cycle under physiologic
conditions
4.2 Which Testing Should Be Selected? 51
Table 4.2 Acronyms of Qmax = peak flow

urodynamic parameters
Q ave = mean flow
Pabd = abdominal pressure
Pves = vesical pressure
Pdet = detrusor pressure
Pura = urethral pressure
PVR = post-void residual
Vinf = infused volume
VV = voided volume
EMG = electromyography
MUP = maximum urethral pressure
MUCP = maximum urethral
closing pressure
invasive screening test which is used to assess the voiding

process and post-void residual urine.
• Filling cystometry is the test of choice for storage
symptoms.
• Pressure/flow study is the test of choice to assess whether
voiding symptoms are due to bladder outlet obstruction or
to an underactive detrusor muscle.
• EMG is the test of choice for assessment of pelvic floor
muscles activity, mostly in neurological conditions.
• Videourodynamics is indicated when anatomical detail is
required in addition to data on lower urinary tract
function.
• Ambulatory urodynamics is a second-line diagnostic tool
when office laboratory urodynamics have failed to achieve
a diagnosis.
52 Chapter 4. Urodynamic Testing: When and Which
Suggested Reading
Collins CW, Winters JC (2014) AUA/SUFU adult urodynamics
guidelines: a clinical review. Urol Clin North Am 41:353–62
Finazzi-Agrò E, Serati M, Salvatore S, Del Popolo G (2013)
Comments on “A randomized trial of urodynamic testing before
stress-incontinence surgery” (New Engl J Med 2012; 366:1987–
97) From the Italian Urodynamic Society. Neurourol Urodyn
32:301–2
Gammie A, Clarkson B, Costantinou C et al (2014) International
Continence Society guidelines on urodynamic equipment perfor-
mance. Neurourol Urodyn 33:370–9
Nager CW, Brubaker L, Litman HJ et al (2012) A randomized trial
of urodynamic testing before stress-incontinence surgery. N Engl
J Med 366:1987–97
Smith A, Bevan D, Douglas HR et al (2013) Management of urinary
incontinence in women: summary of updated NICE guidelines.
BMJ 347:f5170
Swain S, Hughes R, Perry M et al (2012) Management of lower uri-
nary tract dysfunction in neurological disease: summary of NICE
guidance. BMJ 345:e5074
Van Leijsen KB, Kluivers BWJ, Mol SR et al (2012) Can preopera-
tive urodynamic investigation be omitted in women with stress
urinary incontinence? Anon-inferiority randomized controlled
trial. Neurourol Urodyn 31:1118–23
Winters JC, Dmochowsky RR, Goldman HB et al (2012) Urodynamic
studies in adults: AUA/SUFU guideline. J Urol 188(6
Suppl):2464–72
Chapter 5
Voiding Diary and Pad
Testing
Voiding diary and pad testing should be part of the initial

evaluation of any patient complaining lower urinary tract
symptoms.
5.1 Voiding Diary

Voiding diary records the time of micturition and the voided
volume, incontinence episodes, pad usage, and other informa-
tion such as fluid intake and the degree of urgency. Table. 5.1
shows an example of voiding diary recommended by ICS.
The important parameters recorded in a voiding diary
include:
• Urinary frequency during day and night
• Functional bladder capacity (i.e., the average volume
recorded)
• Nocturnal urine output and diurnal urine output
• Number of leakage episodes
• The degree of urgency
• The volume of liquid drunk
DOI 10.1007/978-3-319-33760-9_5,
54 Chapter 5. Voiding Diary and Pad Testing
Table 5.1 Voiding diary recommended by ICS

24-h bladder diary Date
Drinks Urine
Amount Amount Bladder
Time (ml) Type (ml) sensation Pads
6 am
7 am
8 am
9 am
10 am
11 am
Midday
etc.
The voiding diary has multiple advantages:

• It is an inexpensive test.
• It is a practical substitute for cystometry and, in some way,
is even better since the average voided volume on voiding
diary is more physiological than patient’s cystometric
capacity.
• It is a useful tool to evaluate the effect of therapy.
To facilitate patient’s compliance, electronic pocket
recorders have been proposed with data downloaded in the
computer for the analysis. Recently there has also been
introduced an application for iPad and iPhone (Fig. 5.1).
5.2 Pad Testing

Pad testing is the quantification of the amount of urine lost by
measuring the increase in the weight of perineal pads (weighed
pre- and post-testing) used. This provides an assessment of the
severity of incontinence. Different durations from a short
5.2 Pad Testing 55
Figure 5.1 Voiding diary application for iPad and iPhone (Courtesy
of Synappz Medical Apps)
(1-h) test to a 24-h test have been used with provocation vary-
ing from normal everyday activities to defined regimens.
5.2.1 1-h Pad Test
The ICS Standardization Committee has set out a standard

protocol for the 1-h pad test.
• The test is started without the patient voiding.
• Pre-weighed pad is put in place.
• Subject is given 500 ml of mineral water to drink within a
period of 15 min and then sits or reset for further 15 min.
• At half-hour, he is asked to walk including stair climbing
up and down.
56 Chapter 5. Voiding Diary and Pad Testing
• During the remaining period, he is asked to perform sev-

eral activities including:
• Standing up from sitting, ten times
• Coughing vigorously, ten times
• Running on the spot, 1 min
• Bending to pick up small objects from the floor, five times
• Wash hand in running water, 1 min
At the end of the test, the pad is removed and weighed.
5.2.2 24-h Pad Test
Unlike the 1-h pad test, the 24-h pad test has not been
standardized.
In performing the test, few points should be observed:
• The pads should reflect accurately the fluid deposited on
them. For that reason they should be less evaporative than
panty liners and less absorptive than thicker pads (Tena
Lady Normal fulfill perfectly these criteria).
• The pad is pre-weighed within its own snap-lock bag.
• The test is started in the morning and the pads changed
every 4 h during the day. At the end of the day, a final pad
is worn for about 8 h overnight.
• The removed pads can be re-weighed immediately or
alternatively saved in their bag and re-weighed afterward.
If sealed, they hold moisture for at least 7 days.
• Patients do not need to undertake any particular provoca-
tive activities apart from their usual activities.
• 24-h pad test should be performed simultaneously with a
bladder diary in order to get more information as possible.
5.2.3 Interpretation
Physiological range
• Positive 1-h pad test is urine loss greater than 1.4 g.
• Positive 24-h pad test is a loss greater than 8 g.
1-h pad tests are most suitable in establishing initial diag-

nosis, the 24-h test serves most often for evaluation of treat-
ment outcomes, and longer pad tests are used in clinical
studies.
The pad test is an easy-to-perform, inexpensive test that
can be used in clinical research and in daily patient care as
well. Nevertheless only 10 % of clinicians perform the test
routinely.
Suggested Reading
Bright E, Drake MJ, Abrams P (2011) Urinary diaries: evidence for
development and validation of diary content, format and dura-
tion. Neurourol Urodyn 30:348–352
Costantini E, Lazzeri M, Bini V (2008) Sensitivity and specificity of
one-hour pad test as a predictive value for female urinary incon-
tinence. Urol Int 81:153–159
Krhut J, Zachoval R, Smith PP et al (2014) Pad weight testing in the
evaluation of urinary incontinence. Neurourol Urodyn
33:507–510
Kuo HC (2010) Interpreting the voiding diary of patients with lower
urinary tract symptoms. Incont Pelvic Floor Dysfunct 4:105–110
Chapter 6
Noninvasive Urodynamics
Classically, noninvasive urodynamics include uroflowmetry

and post-void residual assessment.
6.1 Uroflowmetry
6.1.1 Definition
Flow is defined by the fluid expelled from the urethra per

unit of time.
The test is a simple, safe, inexpensive, and noninvasive way
of measuring and recording the urinary flow rate during mic-
turition. The aim is to recreate a patient’s natural voiding
pattern.
ICS terminology (Fig. 6.1):
• Flow rate (Q): Volume of fluid expelled via the urethra per
unit time (ml/s)
• Voided volume (Vvoid): Total volume expelled via the ure-
thra (ml)
• Maximum flow rate (Qmax): Maximum measured value of
the flow rate after correction for artifacts
• Voiding time: Total duration of micturition (s)
• Flow time: Time over which measurable flow actually
occurs
DOI 10.1007/978-3-319-33760-9_6,
60 Chapter 6. Noninvasive Urodynamics
Uroflowmetry: ICS recommended nomenclature

Flow rate (ml/sec)
Maximum flow rate
Average flow rate
Voided volume
Time to Time
maximum flow
Flow time
Figure 6.1 Normal flow curve and pattern depicting the terminol-
ogy of ICS
• Average flow rate (Qave): Voided volume divided by the

flow time
• Time to maximum flow: Elapsed time from onset of flow
to maximum flow
6.1.2 Techniques of Measurement
There are two different types of flow transducer:

• Weight transducer: It operates by measuring the weight of
the hydrostatic pressure at the base of collecting cylinder.
Weight variations of collecting device during micturition
generate the flow curve.
• Rotating disk: Urine stream is directed onto a rotating
disk. The power needed to keep the disk rotating at a con-
stant speed is proportional to the flow rate of urine.
Uroflowmetry does not require an elaborated setup. The
instrument should be located in a clean, quiet room preferably
lockable. In some case, it can be actually set up in a toilet.
6.1 Uroflowmetry 61
In women, the examination is performed in a sitting posi-

tion. In some cases, this also applies to man. Most often, how-
ever, the man voids in standing position through the funnel
connected directly to the baker.
The chair ranges from simple commode-like chair to the
most advanced electromechanical chair which is part of a
multichannel urodynamic equipment.
The base plate containing the transducer can be connected to
a single recorder unit (portable flowmeter) or to a multichannel
recording device (integrated flowmeter). There are also “wire-
less” transducers that can be used with the PC (Fig. 6.2).
The ICS recommends specific standards for the equipment:
• A range of 0–50 ml/s for Qmax
• A range of 0–1000 ml for voided volume
• Maximum time constant of 0.75 s
• An accuracy of +5 % relative to full scale
6.1.3 How to Read a Flow Curve
A voided volume of at least 150 ml is necessary to ensure a

reliable interpretation of the curve. In reading a flow curve,
two aspects should be considered:
• Morphology of the curve
• Numerical parameters
6.1.3.1 Morphology of the Curve
The flow can be continuous or intermittent. Flow patterns

can be a useful mean for a presumptive diagnosis. The follow-
ing samples are described:
(a) Normal: It is a bell-shaped curve with Qmax reached in the
initial one third of the void (usually 3–10 s) (Fig. 6.3).
(b) “Compressive” obstruction, e.g., BPH: Pattern of flow
seems normal til Qmax (lower than normal) with a termi-
nal prolongation. Average flow is typically lower than
normal.
62
a b c
Chapter 6. Noninvasive Urodynamics
Figure 6.2 Wireless uroflowmeter. (a) recording unit, (b) micturition chair, (c) male voiding stand, both height adjust-
able. (Courtesy of Albyn Medical)
6.1 Uroflowmetry 63
Flow (ml/s)
Normal “bell shaped” flow curve
Qmax
1/3 of voiding time Time (s)
Figure 6.3 Normal “bell-shaped” flow curve with Qmax reached in

the initial one third of void
(c) “Constrictive” obstruction, e.g., urethral stricture: A low

Qmax is rapidly reached, and the flow rate remains rela-
tively constant, giving to the curve a plateau-shaped
appearance.
(d) “Staccato” curve, e.g., dysfunctional voiding: Fluctuations
in the flow curve due to burst of involuntary external
sphincter contractions during voiding.

(e) Intermittent flow, e.g., abdominal straining or neuro-
pathic sphincter dyssynergia: A flow that stops and starts
several times during voiding (Fig. 6.4).
(f) “Supervoider”: Very high Qmax with very rapid upstroke
and downstroke. Not diagnostic, but people (mostly
females) with detrusor overactivity or stress urinary
incontinence may have a flow rate at the top of the range
(the so-called fast bladder) (Fig. 6.5).
Flow Curve Morphology
a continuous b interrupted
Compressive Staccato
Constrictive Intermittent
Figure 6.4 Flow curves: (a) continuous including compressive

(BPH) and constrictive (urethral stricture) patterns (b) interrupted
including “staccato” (dysfunctional voiding) and intermittent
(abdominal straining and/or detrusor sphincter dyssynergia) patterns
Flow (ml/s) “Supervoider”

50
0
Time (s)
Figure 6.5 “Supervoider” female flow curve

6.1 Uroflowmetry 65
6.1.3.2 Numerical Parameters
Among the different parameters of a flow curve is the value

of Qmax to be commonly used in clinical practice.
Normal Values of Qmax

They are different in males and females.
Footnote
Urodynamic evaluation of lower urinary tract is not a

physiological test. Even if normality in UDS can be
defined, tests must always be interpreted against patient
characteristics, complaints, and symptoms.
In males with no bladder outlet obstruction, the value of

Qmax tends to decrease with age:
• Under 40 years the value is usually over 25 ml/s.
• Over 60 years the value should be over 15 ml/s.
In females, the flow rate is higher than in males of the
order of 5–10 ml/s for a given bladder volume due to the sim-
plified anatomy of the female urethra.
As previously said, abnormally high flow can be observed
in women with stress urinary incontinence where the outlet
resistance is reduced and also in patients which have a signifi-
cant detrusor overactivity.
Flow Nomograms
The value of Qmax is highly dependent on the volume

voided, because the contractile efficiency of the detru-
sor increases in relation to the filling up to a maximum
over the which decreases (Starling law). In practice it is
believed that below 150 ml, the value of Qmax is errone-
ously low as well as above 550 ml. The optimum for flow
analysis should be between 200–400 ml of filling.
Since the value of Qmax is highly dependent on the volume

voided, the study of micturition in men and women has been
hampered by the lack of a normal reference range covering
urinary flow rates over a wide range of voided volumes.
The nomogram charts have been constructed both for the
maximum and average urinary flow rate using statistical trans-
formations of the rough data of flow with the aim to perform a
proper analysis in a wide range of voided volumes (15–600 ml).
The most common are:
• Siroky nomogram (for men over 55 years) (Fig. 6.6)
• Bristol nomogram (for men under 55 years) (Fig. 6.7)
• Liverpool nomogram (for men under 55 years and for
women) (Fig. 6.8)
Footnote
Many of the equipments on the market make the auto-

mated analysis of Qmax directly on the flow nomograms.
Automated analysis should always be verified by the
examiner to avoid inexact reading (see below).
6.1.4 Artifacts
Artifacts in recorded flow curve are quite common.

Therefore electronic analysis may be inaccurate. Automated
data analysis must be verified and documented by inspec-
tion of the flow curve to exclude artifacts. The curves
should always be analyzed and reinterpreted manually by
the examiner.
The following are a few examples:
• Accidental kick to the instrument (Fig. 6.9)
Qmax automatic : 50 ml / s − Qmax real : 30 ml / s

6.1 Uroflowmetry 67
Siroky Nomogram
Male < 55 yrs
Max flow rate
Average
ml/s
30 0
25
–1
20
–2
15
p<0.25
Standard deviation
10
–3
0
0 100 200 300 400 500
Volume (ml)
Qmax: 12 ml/s
Voided volume: 100ml
Ligth blue: unobstructed
Orange: obstructed
Figure 6.6 Siroky nomogram
Footnote
In urodynamics any event of less than 2 s must be con-

sidered accidental, in practice an artifact, with the
exception of pressures that measure coughing.
30 Bristol Nomogram
Male > 55 yrs
26
0
22
Qmax (ml/s)
18
–1 SD
14
10 –2 SD
2
100 200 300 400 500 600 700
Voided volume (ml)
Figure 6.7 Bristol nomogram-1SD appears to be an appropriate

lower limit of normality
Liverpool Nomogram
In female10th percentile is the cut-off between obstruction (<) and unobstruction (>)
In male 25th percentile is the cut-off between obstruction (<) and unobstruction (>)
Qmax (ml/s) 70 95th

90th
60
75th
50
50th
40
25th
30
10th
20 5th
10
0
0 100 200 300 400 500 600
Voided volume (ml)
Figure 6.8 Liverpool nomogram
• Straining (Fig. 6.10)
Qmax automatic : 45 ml / s − Qmax real : 15 ml / s

6.1 Uroflowmetry 69
Accidental Kick
50
40
Flow (ml/s)
30
20
10
0
Time (s)
Figure 6.9 Accidental kick to the instrument. Abrupt peak recorded

by the machine during voiding. Although the computerized reading
shows a Qmax of 50 ml/s, manual assessment denotes a Qmax of 30 ml/s
Flow (ml/s) Straining

50
25
Voided volume (ml)
red: straining flow curve green: manually corrected curve
Figure 6.10 Voiding by straining. Although the computerized read-

ing shows a Qmax of 45 ml/s, manual assessment of flow using smooth
curve denotes an actual Qmax of 15 ml/s
• Fluctuating movement of the urine stream on the rotating

disk (the so-called cruising) (Fig. 6.11)
Qmax automatic : 42 ml / s - Qmax : 30 ml / s

• Compression of the glans: initial high-speed squirt of urine

concomitant with the release of compression (Fig. 6.12)
Qmax automatic : 45 ml / s − Qmax real : 23ml / s

6.2 U
roflowmetry in Pediatric Age
(<15 Years)
The ICCS (International Children’s Continence Society)
fixes the minimum voided volume to be analyzed between 50
and 100 % of bladder capacity calculated according to the age
of the child.
Cruising
50
Flow (ml/s)
25
0
Time (S)
Figure 6.11 “Cruising.” Rhythmic small peaks on the flow curve

due to stream movements. Computerized reading, Qmax: 45 ml/s.
Manual reading, Qmax: 30 ml/s
6.2 Uroflowmetry in Pediatric Age (<15 Years) 71
Flow Curve Artefacts: compression of the glans
50
Flow (ml/s)
25
0
Time (s)
Figure 6.12 Compression of the glans. Initial peak followed a regu-

lar flow curve. Computerized reading, Qmax: 45 ml/s. Manual reading,
Qmax: 23 ml/s
Footnote
Bladder capacity in children may be obtained through

several formulas (see chapter 7 in section “Pressure
flow study in pediatric age”).
Often in practice, a voided volume of 50 ml is considered

as the minimum acceptable. The normal value of Qmax should
correspond to the square root of the volume voided.
Example With a voided volume of 75 ml, Qmax should be

8.6 ml/s.
However, it must be remembered that in children, much
more than in adults, a strong detrusor contraction can com-
pensate for the presence of obstruction and a normal Qmax
should be interpreted cautiously.
Even in children the Liverpool nomogram can be utilized

for an automated analysis of the flow curve differentiating
males from females. In females, due to the simplified urethral
anatomy, the value of Qmax is higher than in males (Fig. 6.13a, b).
Uroflowmetry Nomogram for Maximum Urine Flow Rate in Boys (7–14)

60
95th
50
90th
Maximum Urine Flow Rate (ml/sec)
75th
40
50th
30
25th
20 10th
5th
10
0
20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320 340
Voided Volume (ml)
Uroflowmetry Nomogram for Maximum Urine Flow Rate in Boys (7–14)

60
50
Maximum Urine Flow Rate (ml/sec)
95th
90th
40
75th
50th
30 25th
10th
5th
20
10
0
20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320 340
Voided Volume (ml)
Figure 6.13 Liverpool nomogram in pediatric age: (a) Boys. (b) Girls
6.4 Advantages and Disadvantages of Uroflowmetry 73
6.3 T
he Value of Free Flowmetry
in the Diagnosis of Bladder Outlet
Obstruction (BOO) in Male
Qmax can be used in males to predict, with good approxima-
tion, the presence of bladder outlet obstruction, thus limiting
the use of an invasive pressure-flow study particularly if a
conservative treatment is planned.
The proportion of men with bladder outflow obstruction
with a Qmax < 10 ml/s has been reported at 90 %, whereas 67 %
with a Qmax between 10 and 15 ml/s and 48 % with a Qmax
greater than 15 ml/s will have BOO.
Both detrusor hypocontractility and detrusor hypercon-
tractility can account for the reduced and normal flow in the
remaining cases (Table 6.1).
This distinction is important as patients with low pres-
sure – low flow (detrusor hypocontractility) – may not
improve after prostatic surgery.
In practice, when conservative treatment has failed and
the patient remains symptomatic to the extent that he wishes
to consider surgery, a pressure-flow study is mandatory in
order to assess in a reliable way both the degree of obstruc-
tion and the state of detrusor contractility (see male micturi-
tion nomograms in chapter 7).
6.4 A
dvantages and Disadvantages
of Uroflowmetry
Uroflowmetry is an invaluable way to observe the act of mic-
turition, so that it is an excellent noninvasive screening test.
Table 6.1 Predictive value of uroflowmetry in men with LUTS

Qmax (ml/s) Obstructed (%) Nonobstructed (%)
<10 90 10
10–15 67 33
>15 48 52
By itself, uroflowmetry is unable to discriminate between

an obstruction and a detrusor hypocontractility.
However, as a fairly sensitive indicator of voiding dysfunc-
tion, it can be used as a measure of progression of the disease
or its response to treatment.
6.5 Post-void Residual Urine (PVR)

Post-void residual urine is defined as the volume of urine left
in the bladder at the end of micturition.
The evaluation of the post-void residual is usually comple-
mentary to the registration of the flow curve.
The post-void residual urine is typically measured:
• Invasively by catheterization
• Noninvasively by real-time abdominal ultrasound or
BladderScan
According to the Fourth International Consultation on
Incontinence, ultrasound is the recommended means for
measuring PVR as it is noninvasive and is sufficiently accu-
rate for clinical practice.
BladderScan (Fig. 6.14) is a portable 3D ultrasound device
which measures bladder volume in a quick, accurate, and reli-
able way.
6.5.1 Normal Values of the Post-void Residual
There is no uniformity of views on the values of the normal

post-void residual.
Up to 25 ml, the residue is to be considered normal. Values
ranging between 50 and 100 ml are interpreted in the clinical
context.
Values greater than 150 ml are to be considered pathologi-
cal and require a contextual ultrasound evaluation of the
upper urinary to exclude a dilatation.
A more precise way to assess post-void residual is through
voided percentage (Void%). Voided percentage is the numerical
6.6 New Noninvasive Urodynamic Techniques 75
Figure 6.14 The BladderScan (Courtesy of Caresono)
description of the voiding efficacy which is the proportion of blad-

der content emptied. It can be calculated through the formula:
éë( volume voided / volume voided + PVR ) *100 ùû .

Void% may be used especially in the follow-up of patients

to verify changes in voiding function in addition to voided
volume and PVR.
6.6 N
ew Noninvasive Urodynamic
Techniques
In the recent years, there has been a growth of interest in non-
invasive urodynamic techniques in an attempt to maximize
diagnostic information before resorting to conventional uro-
dynamics which are invasive, time consuming, and expensive.
There are, in fact, a lot of controversies around the risk/

benefits of pressure-flow study.
Although the literature clearly demonstrates the utility of
a diagnosis of obstruction before undergoing surgery for
BOO, many clinicians believe that the risks associated with
the test are not justified by the modest improvement in the
chance of a good outcome.
The availability of alternative techniques to estimate blad-
der pressure during voiding noninvasively could potentially
help to overcome the problem.
6.6.1 Bladder/Detrusor Wall Thickness (DWT)
The assessment of bladder wall thickness has been proposed

as a noninvasive approach to BOO since obstruction is usu-
ally associated with detrusor hypertrophy leading to an
increased wall thickness.
To measure the DWT, it is necessary to use a high-
frequency transducer (7.5 MHz) and enlarge by approximately
10× the image of the bladder wall. The measurement should
be done with at least 250 ml of urine in the bladder. The
detrusor muscle presents as a hypoechogenic image.
(Figure 6.15) All parts of the bladder wall have the same
thickness, but usually the measurement is done at the dome.
6.6.1.1 Interpretation
The threshold value for BOO is not well defined. Some stud-
ies propose a value greater than 2 mm, others a value greater
than 4 mm.
6.6.2 Penile Cuff Compression Techniques

The principle of these tests is to interrupt the flow at its maxi-
mum value and measure the bladder isovolumetric pressure
which theoretically correlates with detrusor performance.
6.6 New Noninvasive Urodynamic Techniques 77
Figure 6.15 Ultrasound evaluation of detrusor wall thickness

(DWT). Detrusor wall thickness measured at bladder dome (red
arrow) should be less than 2–4 mm in normal adults
A specially designed cuff is placed around the shaft of the

penis and is temporarily inflated during voiding to interrupt
the flow. The cuff pressure required to interrupt voiding pro-
vides a measure of bladder isovolumetric pressure (Fig. 6.16).
6.6.2.1 Interpretation
In healthy volunteers, the cuff pressure overestimates the

bladder pressure by 14.5 +/−14 cmH20.
Combining the values of maximum flow rate and the cuff-
occluding pressure, a nomogram classifies patients as
obstructed, equivocal, and nonobstructed (Fig. 6.17).
Pcuff
Flow
meter
Figure 6.16 Setup of penile cuff compression technique

ICS Nomogram of Penile Cuff Compression Technique

Penile cuff pressure (cm H2O)
200
160 Obstructed
120
Equivocal
80
40
Non-Obstructed
0
5 10 15 20
Qmax (cm H2O)
Figure 6.17 ICS nomogram of penile cuff compression technique
Suggested Reading
Asimakopoulos AD, DeNunzio C, Kocjancic E et al (2016)
Measurement of post-void residual urine. Neurourol Urodyn
35:55–57
Drinnan M, McIntosch S, Robson W et al (2003) Inter-observer
agreement in the estimation of bladder pressure using a penile
cuff. Neurourol Urodyn 22:296–300
Griffith C et al (2002) Noninvasive measurement of bladder pres-
sure by controlled inflation of a penile cuff. J Urol
167:1344–1347
Griffiths CJ, Pickard RS (2009) Review of invasive urodynamics and
progress towards non-invasive measurements in the assessment
of bladder outlet obstruction. Indian JUrol 25:83–91
Gupta DK, Sankhwar SN, Goel A (2013) Uroflowmetry: nomograms
for healthy children 5 to 15 years old. J Urol 190:1008–1013
Haylen BT, Ashby D, Sutherst JR et al (1989) Maximum and average
urine flow rate in normal male and female populations – the
Liverpool nomograms. Br J Urol 64:30–38
Health Quality Ontario (2006) Portable bladder ultrasound : an

evidence-based analysis. Ont Health Technol Assess Ser 6:1–51
Jarvis TR, Chan L, Tse V (2012) Practical uroflowmetry. BJU Int
110(Suppl 4):28–29
Kadow C, Howells S, Lewis P, Abrams P. A flow rate nomogram for
normal males over the age of 50. Proceedings of the 15th annual
meeting of the International Continence Society, London, 1985:
138–9
Kajbafzadeh AM, Yazdi CA, Rohui O et al (2005a) Uroflowmetry
nomogram in Iranian children aged 7 to 14 years. BMC Urology
5:3
Kajbafzadeh AM, Yazdi CA, Rouhi O et al (2005b) Uroflowmetry
nomogram in Iranian children aged 7 to 14 years. BMC Urol 5:3
Oelke M (2010) International Consultation on Incontinence-
Research Society (ICI-RS) report on non-invasive urodynamics:
the need of standardization of ultrasound bladder and detrusor
wall thickness measurements to quantify bladder wall hypertro-
phy. Neurourol Urodyn 29:634–639
Oelke M, Hofner K, Jonas U et al (2007) Diagnostic accuracy of non-
invasive test to evaluate bladder outlet obstruction in men: detru-
sor wall thickness, uroflowmetry, postvoid residual urine and
prostate volume. Eur Urol 57:827–835
Reynard JM, Peters T, Abrams P, Lim C (1996) The value of multiple
free-flow studies in men with lower urinary tract symptoms. Br
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Reynard JM, Yang Q, Donovan JL et al (1998) The ICS-BPH study:
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development. J Urol 122:665–668
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76:16–20
Chapter 7
Invasive Urodynamics
There are two principal methods of invasive urodynamic

investigation:
• Conventional urodynamics
• Ambulatory urodynamics
Conventional urodynamics usually take place in the uro-
dynamic laboratory and involve artificial bladder filling
(Fig. 7.1).
Ambulatory urodynamics is performed outside the clinical
setting involving natural filling of the bladder and reproduc-
ing the subject’s everyday activities.
7.1 Conventional Urodynamics

Conventional urodynamics include two distinct phases:
• Filling phase or cystometry
• Voiding phase or pressure-flow study
7.1.1 The Equipment
In the market, there are several urodynamic equipments, all

with sophisticated software to help the examiner with the
correct use of the instrument during the examination. At the
DOI 10.1007/978-3-319-33760-9_7,
82 Chapter 7. Invasive Urodynamics
Inf. Volume
saline/contrast
medium
Pabd
Pdet
Pves
flowmeter EMG
flow rate
Figure 7.1 Diagram of urodynamic setup
end of the study, all data from the patient are stored on a
database for any revaluation of the case and subsequent sta-
tistical processing (Fig. 7.2).
The equipment to conduct conventional urodynamics
should have a set of minimum standards including:
• Three recording channels, two for pressures and one for
flow
• Infused volume recorded graphically or numerically
• Event annotation method to mark information about sen-
sation and additional comments during the study
• Measured (Pves, Pabd, Flow, EMG) and derived (Pdet)
signals must be displayed continuously over time with an
order varying in the different equipments including
(Fig. 7.3):
– Flow
– Voided volume
– Pabd
– Pves
– Pdet
– EMG
– Inf. volume
7.1 Conventional Urodynamics 83
Figure 7.2 Multichannel urodynamic equipment (Courtesy of Albyn

Medical)
CONVENTIONAL URODYNAMICS: sequence of displayed signals
Flow
Voided vol.
Pabd
Pves
Pdet
EMG
Inf. vol
Figure 7.3 Display of signals
• Detection ranges
– Pressure: 0–250 cmH2O
– Flow: 0–50 ml/s
– Infused volume: 0–1000 ml
• No loss of data for pressures up to 250 cmH2O and flow up
to 50 ml/s
7.1.2 Urodynamic Manufacturers and Choice

of the Equipment
Table 7.1 includes a comprehensive but incomplete list of
urodynamic manufacturers.
The type of equipment is strictly related to the volume of
practice.
Any private practice office should be able to perform uro-
flowmetry and post-void residual assessment.
Small community hospitals should be able to perform a
multichannel urodynamics, while large referral centers should
Table 7.1 List of major companies involved in the construction of

urodynamic equipments
Company Headquarters
Laborie Canada
Mediwatch – Dantec United Kingdom
Medical Measurement System Netherlands
(MMS)
Albyn Medical United Kingdom, Spain
HC Italia Italy
Memphis bioMedica Italy
Andromeda Germany
Neomedix Australia
Mindray Medical International China
be equipped to perform a more sophisticated testing includ-

ing integration of fluoroscopy.
On the assumption that urodynamic room should be pri-
vate and quiet as possible in order to minimize anxiety for the
patient, the space available is an important factor in deciding
what type of machine is more appropriate for a specific prac-
tice. A dedicated UDS room allows for a more elaborated
setup, whereas a less sophisticated mobile system is definitely
more suitable if one plans to move from a room to another.
Recently introduced wireless urodynamic systems allow
maximum flexibility for the operator and investigation room
setup since the recording unit is close to the patient, whereas
the PC display and printer can be located at operator prefer-
ence (Fig. 7.4).
In addition, a simple uroflow commode may be sufficient
in the office or small community hospital, whereas a motor-
ized chair with multiple adjustments will be more appropri-
ate in a referral center where UDS testing on patient with
limited mobility (neurogenic bladder) is more common
(Fig. 7.5).
Figure 7.4 Wireless urodynamic equipment (Courtesy of Albyn

Medical)
Figure 7.5 Electrically adjustable urodynamic chair (Courtesy of

Albyn Medical)
7.1.3 The Catheters
There are several commercially available catheters for urody-

namic examination. The major difference between them is
the method of pressure measurement, namely:
• Fluid-filled catheter with external pressure transducer
• Air-charged catheter with external pressure transducer
• Microtip transducer
Water filled double lumen catheter
Figure 7.6 Fluid-filled bladder catheters (Courtesy of Coloplast)
Fluid-filled catheters function by recording the pressure

into the bladder (Fig. 7.6) and rectum (Fig. 7.7) which is trans-
mitted to the strain gauge of the external transducer through
a noncompressible column of water inside the catheter and
connecting line.
Advantages of these catheters are that they are at low cost
and disposable. The major disadvantage is the potential for
signal artifacts due to obstruction of intraluminal air bubble
within the catheter (damping phenomenon).
Air-charged catheters (Fig. 7.8) have a small balloon over-
lying the catheter tip that separates the recording system from
the bladder cavity. The catheter is filled with air and the pres-
sure is transmitted directly from the catheter tip to the exter-
nal transducer. Advantages of these catheters are the absence
of classical damping phenomenon and the lack of motion
artifacts created by movement of the line. Disadvantages
Rectal catheter
Figure 7.7 Rectal catheter
Air-charged catheters
Figure 7.8 Air-charged catheters (Courtesy of Mediwatch)
include a slow response to pressure variations and in general

an attenuation of the transmitted signal (they are perma-
nently overdamped).
Figure 7.9 Solid-state (microtip) catheters
Microtip catheters (Fig. 7.9) show a small transducer

mounted on the tip that detects pressure changes by means
of strain. This is converted into an electric signal which is
amplified and transmitted to a semiconductor for conversion
into a pressure measurement. The major advantage of this
catheter is a faster response in pressure change recording
and minimal motion artifacts that make them particularly
suitable for ambulatory urodynamics. Disadvantages include
the cost, the need for sterilization, fragility, and rotation
error.
Footnote 1
The ICS recommends a fluid-filled catheter with external
transducer for routine urodynamic testing.
7.2 Preparation of the Patient 91
Footnote 2
With any external transduction device (water-filled and
air-charged catheters), it is essential to ensure that the
transducer is mounted at the level of the superior edge
of the pubis symphysis that is considered at the same
level of the bladder (zeroing the pressure). A failure to
positioning external transducer at this level will result
in erroneously high-pressure reading (if below the sym-
physis pubis) or low (if above the symphysis pubis).
7.2 Preparation of the Patient

Multichannel urodynamic testing requires an optimally
informed patient (see Appendix A).
Due to short-time catheterization, prophylactic antibiotics
are unnecessary in an uncompromised patient. However, if
high incidence of urinary tract infections after urodynamic
testing is observed in a given practice, the entire procedure
should be strictly rechecked in terms of sterility. Laxatives are
also unnecessary since they might cause unwanted bowel
overactivity during the test. In any case the patient should be
asked to arrive possibly with an empty bowel.
Although voiding is presumably negatively influenced in a
situation of mental stress, there is no clear evidence that void-
ing in unphysiological laboratory circumstances is signifi-
cantly altered.
However, a quiet ambience with as little number as possi-
ble of persons involved is strictly recommended during uro-
dynamic testing.
7.2.1 Setup of the Patient, Step by Step

Step 1: EMG electrode placement
The first step is to position the electrodes on the skin around
the patient anus and on the thigh to act as the ground lead.
Step 2: Sterilizing the urethra

Prepare the urethra with Betadine wiping once downward
over the meatus and then once on either side of the
meatus.
Step 3: Post-void residual urine measurement
Drain the bladder with a catheter to obtain a post-void
residual urine measurement. An alternative method is
to place the cystometry catheter into the bladder and
utilize the filling channel to evacuate the post-void
residual with a syringe.
Step 4: Catheter insertion into the bladder and rectum
In female advance the catheter into the bladder eight (8)
to ten (10) centimeters. In males, do not advance it
more than 24 centimeters.
For rectal placement, apply lubricant around the anal
canal. Place the catheter to a depth of approximately
ten (10) to fifteen (15) centimeters. You can test
whether the placement is correct by asking the patient
to tighten his or her anal sphincter. If the pressure
shows an upward deviation in catheter pressure read-
ing, the catheter is not deep enough and should be
placed a little deeper. As an alternative for female
patients, you can check placement of a rectal catheter
by positioning a finger in the vagina and feel whether
the rectal catheter is sliding along the anterior wall of
the rectum in a straight fashion. This ensures more accu-
rate abdominal pressure sensing and reduces the risk of
stool affecting the test. If the patient has chronic consti-
pation, i.e., neurogenic patients, an enema before test-
ing eliminates this possibility.
Once inserted, each catheter should be securely fixed and
then connected to its respective cable.
Step 5: Flushing (Fig. 7.10a)
Once the catheters are fixed in position and connected
to the transducers, the crucial next step is to free them
of air inside the channel by flushing with infusion
fluid, since any amount of air in the system from the
syringe to the tip of the catheter may dampen the
recording.
a FLUSHING b ZEROING c RECORD
Syringe
Transducer dome
open to air
to patient to patient to patient
3-way TAPS : THE KEY OF MULTICHANNEL URODYNAMICS
Figure 7.10 3-way taps: the key of multichannel urodynamics.

Diagram showing position of 3-way taps between transducer and
syringe and between transducers and tubing to the patient. Various
positions of the taps allow flushing of the tubing, zeroing to atmo-
spheric pressure and internal pressure measurement
Step 6: Zeroing UDS machine (Fig. 7.10b)

The next step is zeroing the machine. In this procedure the
3-way taps, located at the tip of the syringe and at the
beginning of connecting cable and at the dome of the
transducer, play a pivotal role. All the transducers are
measuring atmospheric pressure (taken as zero) at a
given point in relation to the patient bladder. By con-
vention, this point is the superior border of the symphy-
sis pubis.
Both the transducers (Pves and Pabd) are placed at the
abovementioned level. The syringe and catheter con-
nection is blocked, while the 3-way taps of the transduc-
ers are opened to atmospheric pressure and the “zero
all” button is pressed. By this way, all the three lines
Pves, Pabd, and Pdet (resulting from the previous two)
show “zero” reading.
At this point, the 3-way connector of the cable is open so

that the transducers are exposed to internal pressure while
are cut off from the atmospheric pressure (Fig. 7.10c). This
shows the pressure inside the bladder and rectum according
to the patient position (Fig. 7.11).
It is extremely important that initial pressures are in the
expected range (Table 7.2), since if measured pressures lie
outside of this range, a technical problem exists which needs
to be rectified.
Pdet should show a near-zero value (<6 cmH2O) since
Pves and Pabd are equal and detrusor activity is absent with
bladder empty. If Pdet results positive or negative, minor
BASELINE PRESSURES CHECK

Supine Seating
Pabd
40
20
0
Pves
15
5
0
Pdet
6
0
Figure 7.11 Baseline pressure checking. Expected resting range of

abdominal and vesical pressures
Table 7.2 Initial resting pressures

Patient position
Plausible values (cmH2O) Supine Seating Standing
Pves 5 15 30
Pabd 20 40 50
corrections can be done by the computer software utilizing

the “Pdet to zero” button.
Footnote
The “zero” of the machine can be checked at any time
during the test by turning the tap so it is open to atmo-
sphere, if artifacts are suspected.
7.2.2 Microtip and Air-Charged Catheters
Microtip and air-charged catheters are set to “zero” while

outside the patient.
For microtip catheters, the reference height is the trans-
ducer’s itself, while for air-charged catheters, the reference
height is at the position of the internal balloon. Therefore,
using these systems is difficult to ensure that intra-abdominal
and intravesical lines are equal. This situation is worsened by
changing patient position. For example, in supine position the
rectal line is likely to be lower than the vesical line, while in
standing position, the rectal line may be higher than the vesi-
cal line. However, in practical terms, these differences don’t
seem to influence significantly the results.
Step 7: Checking the quality of signals (Fig. 7.12).
The quality of signals is checked by asking the patient to gen-
tly cough. Both Pabd and Pves respond equally with a rapid peak
and rapid drop and the detrusor line should be unaffected.
A small biphasic deflection is normal, but any rise or fall
in the detrusor pressure during cough suggests a dampening
in the vesical or abdominal system.
The quality of signals should periodically be checked dur-
ing filling (every 50 ml), at the end of filling, and after voiding
to minimize artifacts.
Footnote
Pabd and Pves recordings are “live,” showing minor
variations of breathing or talking which should not
appear in Pdet.
QUALITY CONTROL OF THE SIGNALS
Pdet=Pves - Pabd
a COUGH
Pves
Pabd
Pdet
normal
b COUGH
c COUGH
Pves
Pves
Pabd Pabd
Pdet
Pdet
problems in Pabd problems in Pves
Figure 7.12 Quality control of the signals: (a) coughing shows Pabd
and Pves responding correctly. Pdet shows a typical biphasic artifact
due to timing differences between the recording of Pabd and Pves.
(b) Coughing shows Pabd not responding correctly. (c) Coughing
shows Pves not responding correctly
7.3 Filling Phase (Cystometry)

Once good signal transmission is appreciated, bladder filling
can commence.
Usually 0.9 % physiological saline is used.
For a neurologically intact adult, the filling rate is usually
50 ml/min. For neurological patients a less provocative rate
such as 10–20 ml/min is recommended. Infusion fluid should
be at room temperature (20 °C) since low temperature can
induce a false detrusor overactivity particularly at low blad-
der volume.
During filling the patient should be asked to cough every
minute or every 50 ml of filling in order to evaluate a good
7.3 Filling Phase (Cystometry) 97
subtraction of pressure. When lost, the test should be stopped

and the lines checked again. The EMG, when recorded,
should show a deflection as well.
Filling phase starts when filling commences and ends when
the patient in consequence of a strong stimulus decides to
empty the bladder or the examiner in front of an adequate
filling volume decides for “permission to void.”
The aim of this part of study is to assess:
• Detrusor function
• Bladder sensation
• Bladder compliance
• Bladder capacity
• Urethral function
7.3.1 Detrusor Function
The normal detrusor function is to allow the bladder filling

with little or no changes in pressure.
The presence of involuntary contractions, spontaneous or
provoked, during filling of the bladder is defined as detrusor
overactivity.
Footnote 1
There is a cutoff value for the significance of an invol-

untary contraction. Conventionally values lower than
5 cmH2O are considered of little significance.
Footnote 2
Provocative maneuvers are defined as techniques used
during urodynamic investigation in an effort to provoke
detrusor overactivity. Examples of provocative maneu-
vers include rapid filling, cool infusion medium, and
postural changes.
7.3.1.1 Detrusor Activity
There are two patterns of detrusor overactivity:
1. Phasic detrusor overactivity

2. Terminal detrusor overactivity
The phasic overactivity is defined by fluctuating wave forms

which may or may not lead to urinary incontinence (Fig. 7.13).
The occurrence of involuntary detrusor contractions may be
observed in normal asymptomatic patients with a rough inci-
dence of 8 %. The condition (also called “occult overactivity”)
may be situational due to sensitivity of urethral catheter or to
rate of filling or to low temperature of infusate. In most of the
cases, however, the significance of this pattern remains unknown.
Terminal detrusor overactivity is defined as a single
detrusor contraction occurring at cystometric capacity, which
cannot be suppressed and usually results in complete bladder
emptying. Characteristic of this condition is the reduction of
PHASIC DETRUSOR OVERACTIVITY
Max Capacity
Inf.Vol (ml) Urgency
SD
FD
Pabd (cmH20)
Pves (cm H20)
Pdet (cmH20)
Leak
Flow
Time (min)
Figure 7.13 Phasic detrusor overactivity. Waves of detrusor contrac-

tions occurring at SD and urgency with a urine leak at latter sensa-
tion just before maximum bladder capacity (cystometric capacity)
attainment
warning time, i.e., the time that elapses between the strong
desire to void and voiding contraction (Fig. 7.14).
Detrusor overactivity may also be qualified according to
the cause, i.e.:
Idiopathic detrusor overactivity, when there is no definite
cause
Neurogenic detrusor overactivity, when there is a relevant
neurological condition
Other patterns of detrusor overactivity include a combina-
tion of phasic and terminal detrusor overactivity and sus-
tained high-pressure detrusor contraction in spinal injury
patients with detrusor-sphincter dyssynergia.
7.3.1.2 Bladder Sensation
The term is covering all the sensations that the individual

feels during bladder filling.
A normal subject is aware of increasing sensation with
bladder filling up to a strong desire to void.
TERMINAL DETRUSOR OVERACTIVITY
Urgency
Inf. Vol (ml) SD reduced warning time
FD
Pabd (cm H20)
Pves (cmH20)
Pdet (cmH20)
Leak
Flow (ml/s)
Time (min)
Figure 7.14 Terminal detrusor overactivity. Strong detrusor con-

traction occurring at urgency and leading to complete bladder emp-
tying. Warning time, i.e., the time between the strong desire to void,
and beginning of micturition is typically reduced
The sensitivity of the bladder is defined by four specific

times of the cystometry:
• First sensation of filling: Volume at which the patient real-
izes that the bladder is filling
• First stimulus of voiding: volume at which the patient
experiences for the first time the need to urinate
• Strong desire: Volume at which it becomes difficult to
postpone micturition.
• Maximum cystometric capacity: Volume beyond which
you cannot put off micturition
The maximum cystometric capacity (normally between
400 and 500 ml) represents the end of the filling phase.
Footnote
As previously noted, the maximum cystometric capacity
is a reliable value, but it is relatively unphysiological
since it is acquired through a laboratory test. For this
reason, it may differ from the functional bladder capac-
ity obtained by the analysis of voiding diary which is
more physiological and better represents the condition
of the patient.
Clinically, the sensitivity can be reduced, when the sensa-

tions are felt to higher volume filling, or absent when the feel-
ings are not felt by the patient. In these cases, mostly
neurological, bladder filling is perceived as vague sense of
suprapubic weight or through autonomic phenomena (auto-
nomic dysreflexia).
The sensitivity can, conversely, be increased when the sen-
sations are experienced at smaller volumes of filling.
Bladder oversensitivity can be defined as an increased
perceived bladder sensation during bladder filling.
The condition shows specific cystometric findings including:
• An early first desire to void
• An early strong desire to void which occurs at low bladder
volume
BLADDER HYPERSENSITIVITY
Inf. Vol.(ml)
Urgency
SD
FD
Pabd (cmH20)
Pves (cmH20)
Pdet (cmH20)
leak
Flow (ml/s)
Time (min)
Figure 7.15 Bladder oversensitivity. Strong desire to void occurring

at low filling volume without any detrusor contraction. Increased
sensation leads to small leakage of urine
• A low maximum cystometric capacity without any abnor-

mal increases in bladder pressure (Fig. 7.15)
An increased sensitivity can lead to a real pain in the
bladder.
Oversensitivity is a characteristic condition of interstitial
cystitis and related syndromes (painful bladder syndrome,
pain bladder syndrome).
Footnote 1: Urge vs. Urgency
The ICS definition of urgency assumes an abnormal or

pathologic bladder sensation that is distinguishable
from the normal physiologic sensation of urge to void
during a normal bladder-filling cycle. The latter is char-
acterized by a pattern of sensations that increases in

intensity with increasing bladder volume, resulting in
normal, controlled, voluntary voiding. Essential to the
definition of normal urge is the ability to defer voiding
for a certain amount of time, even when the urge sensa-
tion is at its maximum. In contrast, urgency, as charac-
terized by the ICS, indicates a sensation of sudden onset
such that it is difficult for the patient to defer voiding
once the sensation is perceived.
Footnote 2
Filling cystometry is a semi-objective test especially with
regard to bladder sensation. Communication between
the examiner and the patient who reports the sensations
felt is extremely important. In the past written notes on
recording paper and today event marks on the screen of
the recording unit are a key part of urodynamic testing.
7.3.1.3 Compliance
Bladder compliance describes the relationship between

change in bladder volume and change in detrusor pressure.
Practically, it describes the inherent ability of the bladder
to vary its volume without that the pressure inside it increases
significantly.
Compliance is calculated by dividing the volume change
(V) by the change in detrusor pressure (Pdet) during that
change in bladder volume according to the formula:
Compliance = change in volume / change in pressure
It is expressed in ml/cmH2O.
The detrusor pressure (and corresponding bladder volume)
is calculated at cystometric capacity or immediately before the
start of any detrusor contraction that causes significant leakage
(and therefore causes the bladder volume to decrease, affect-
ing compliance calculation) (Fig. 7.16).
BLADDER COMPLIANCE
Max Cystometric Capacity
400
Inf.Vol (ml) 300
200
100
Pdet (cmH20)
100
REDUCED
10
NORMAL
0
Figure 7.16 Bladder compliance. Bladder compliance is usually

calculated at cystometric capacity or immediately before the start of
a detrusor contraction that causes significant leakage
The normal value of compliance is lower than 30–40 ml/

cmH2O.
Compliance is reduced when its value is greater than
30–40 ml/cmH2O.
In practice a cut-off value of 10 cmH2O at cystometric
capacity is often used.
Footnote
Sometimes a reduced compliance may be an artifact
due to a rapid filling of the bladder; in these cases it is
advisable to repeat the filling at a lower infusion rate. If
reduced compliance persists even in these conditions,
the value has to be considered real.
7.3.1.4 Detrusor Leak Point Pressure (DLPP)

In patients with poor compliance (myelodysplastic children,
radiation cystitis following radiotherapy to pelvic tumors),
detrusor pressure increases incrementally as the bladder fills,
ultimately exceeding sphincteric pressure, resulting in urinary
leakage.
DETRUSOR LEAK POINT PRESSURE
300 Max Capacity

200
Inf Vol (ml) 100
Pdet (cmH20)
100
safe bladder capacity risk upper tract deterioration
40 cmH20
leak
Flow (ml/s)
Caution should be used in continuing filling when pressures are in excess of 40cmH20
Figure 7.17 Detrusor leak point pressure. There is a close relation-

ship between DLPP and upper urinary tract deterioration. The
“safe” bladder capacity is defined as the volume of fluid held at
pressure below 40 cmH2O
The measurement of DLPP is relevant in patients with

poor bladder compliance for the risk of upper tract deteriora-
tion. DLLP is defined as detrusor pressure at which urinary
leakage occurs in the absence of detrusor overactivity or
abdominal straining. A value greater than 40 cmH2O increases
the risk of upper tract damage. The bladder volume at which
detrusor pressure equals 40 cmH2O is considered the patient’s
“safe” bladder capacity. Therefore, if the bladder volume
remains below the maximal safe bladder capacity, the detru-
sor pressure should remain safe (Fig. 7.17).
Footnote
The detrusor pressure required to overcome urethral
resistance and cause leakage is not an indicator of con-
tinence or sphincteric function.
7.3.2 Urethral Function
The assessment of urethral function during bladder filling

includes:
• Demonstration of leakage during an effort (usually cough)
Measurement of abdominal leak point pressure
7.3.2.1 Urodynamic Stress Incontinence
The ICS defines urodynamic stress incontinence as urinary

leakage seen during filling cystometry in the presence of
raised abdominal pressure but in the absence of a detrusor
contraction. Coughing to demonstrate urodynamic stress
incontinence is best performed with a patient sitting on the
electronic urodynamic chair with a bladder filling of
150 ml.
Leakage seen at the urethral meatus during coughing
while the cystometric trace shows no evidence of detrusor
contraction confirms the diagnosis (Fig. 7.18). When a
prolapse is present, it should be gently reduced by a finger
and the patient asked to cough again.
7.3.2.2 Abdominal Leak Point Pressure (ALPP)
Abdominal leak point pressure measures the vesical pressure

at which leakage occurs during a voluntary increase of
abdominal pressure in the absence of detrusor overactivity.
The measurement of ALPP is relevant in patients with stress
urinary incontinence since a low value is associated with an
intrinsic sphincteric deficiency that could negatively affect
the outcome of surgery.
Technique
The test is performed in sitting or standing position.
When the bladder volume is 200 ml, the patient performs a
progressive Valsalva maneuver until leakage occurs. The pro-
cedure is facilitated by having one person observe for leakage
URODYNAMIC STRESS INCONTINENCE
Max Cystometric Capacity
In. Vol (ml) 200
Pabd (cmH20)
Pves (cmH20)
Pdet (cmH20)
Flow (ml)
Figure 7.18 Urodynamic stress incontinence. Leakage occurs dur-

ing cough without any concomitant detrusor contraction
and one person observe for pressure variations. Performing the

test several times and then determining an average pressure
value increase the accuracy of measurement. If no leakage
occurs and the pressure is greater than 120 cmH2O, coughing is
used to induce leakage. Because it is difficult to determine an
accurate value during cough, when leakage occurs it is usually
considered a consequence of a high ALPP (see below).
Interpretation
In women with SUI, an ALPP of 60 cmH2O or less indicates a
significant degree of ISD, whereas an ALPP of 90 cmH2O or
more is usually associated with pure urethral hypermobility.
ALPP values between 60 and 90 cmH2O form a gray area in
which hypermobility and ISD usually coexist (Fig. 7.19).
If the patient does not leak and significant pressures have
been generated by Valsalva or coughing, the catheter is
ABDOMINAL/VALSALVA LEAK POINT PRESSURE

Inf. vol (ml) 200
valsalva valsalva valsalva valsalva cough

Pves (cmH20)
no leak
normal urethra
120 cmH20
leak
hypermobility
90 cmH20
leak
grey zone
60 cmH20
leak
ISD
Figure 7.19 Abdominal leak point pressure. ALPP measures the

ability of the urethra to resist to expulsive forces of the abdominal
pressures (urethral competence) and is the amount of the abdomi-
nal pressure required to overcome urethral resistance and produce
urine leakage
removed, and again Valsalva or coughing is used to demon-

strate leakage. If leakage occurs only with vigorous coughing,
the cause is usually urethral hypermobility. If no leakage is
demonstrable, a bladder cause should be considered.
Pitfalls in ALPP Testing

The inability of the patient to generate sufficient pressure
during testing (anxiety) can be a frustrating problem. Most of
the time, reassurance and simple instructions are sufficient to
overcome the problem.
Coexisting detrusor overactivity can confound ALPP mea-
surement and results should be considered unreliable.
The urodynamic catheter may obstruct the urethra. This
situation is relatively uncommon in women, but is extremely
common in men after radical prostatectomy. In this situation,
unintubated (without catheter) measurement utilizing rectal
pressure solves the problem.
The presence of prolapse can alter the ALPP both by

compressing the urethra and dissipating the abdominal
forces.
Any prolapse should be reduced without obstructing the
urethra and ALPP repeated.
7.3.3 Quality Control of Recording at the End

of Filling Phase
At the end of filling phase, a quality control of the traces
should be done by verifying that the pressures recorded
(Pves, Pabd, and Pdet) are within the normal ranges.
Box 7.1: Normal Pressure Range at the End of Filling Phase
• Pves: 30–55 cmH2O

• Pabd: 22–46 cmH2O
• Pdet: 3–12 cmH2O
If the values do not fall into these ranges, the filling should
be repeated or, at least, the results carefully evaluated.
7.4 Voiding Phase (Pressure-Flow Study)

Voiding is described in terms of detrusor and urethral
function and assessed by measuring urine flow rate and
voiding pressures. Pressure-flow studies of voiding are the
method by which the relationship between pressure in the
bladder and urine flow rate is measured during bladder
emptying.
The emptying phase begins when the patient, as a result of
the stimulus, or the instruction to void given by the examiner
starts the micturition and ends when he/she considers the
voiding has finished.
7.4 Voiding Phase (Pressure-Flow Study) 109
Footnote
It’s always advisable to avoid an overfilling of the blad-

der, because it is believed that over 650–700 ml, the
informations obtained are unreliable and useless.
Initially the detrusor contracts without reducing the vol-

ume of the bladder.
This phase, called isovolumetric, leads to the opening of
the bladder neck at the end of which urine begins to flow
along the urethra.
At this point bladder volume decreases gradually until the
bladder is completely emptied.
The pressure events during voiding have been defined by
ICS (Fig. 7.20).
7.4.1 Definitions
• Premicturition pressure is the pressure recorded immedi-

ately before the initial isovolumetric contraction.
• Opening pressure is the pressure recorded at the onset of
urine flow.
• Opening time is the time elapsed from the initial rise in
detrusor pressure and the onset of flow.
• Maximum pressure is the maximum value of measured
detrusor pressure.
• Pressure at maximum flow is the lowest detrusor pressure
recorded at maximum measured flow rate.
The above schematic diagram does not apply to all voids,
because physiologically there are at least four types of mech-
anism of voiding:
• By prevalent detrusor contraction: when Pves and
Pdet increase simultaneously, while Pabd remains
unchanged
Pressure Flow Measurements according to ICS

Intravesical
opening
pressure
Intravesical
Pves Intravesical
contraction
premicturition
Intravesical Maximum pressure at
pressure
pressure intravesical maximum flow
(cm H2O) pressure
Abdominal Abdominal
opening pressure at
Pabd pressure maximum
Abdominal flow
Abdominal
pressure premicturition
pressure
(cm H2O)
Detrusor Detrusor
opening pressure at
Pdet pressure maximum flow
Detrusor Detrusor
premicturition
pressure Maximum
pressure
(cm H2O) detrusor
pressure
Qura
Flow
rate Maximum
(ml/s) flow
Opening
time
Figure 7.20 Pressure events during voiding according to ICS
• By prevalent abdominal straining: when Pabd and Pves

increase simultaneously, while Pdet remains unchanged
• Mixed (the most common): when pressure rise affects
simultaneously Pves, Pabd, and Pdet (as shown in the
diagram)
• By prevalent urethral relaxation (common in female):
when Pves, Pabd, and Pdet remain unchanged during urine
flow
Footnote 1
The type of micturition should be described in the
report of the pressure-flow study.
Footnote 2
Detrusor pressure during voiding may be lower than
bladder pressure as a result of a decrease in abdominal
pressure (Pabd) secondary to the relaxation of the pel-
vic floor.
Box 7.2: Normal Pressure Ranges at Qmax
• Pves@Qmax: 15–120 cmH2O

• Pabd@Qmax: 20–40 cmH2O
• Pdet@Qmax: 44–107 cmH2O
• Qmax: 5–50 ml/s
Normal pressures ranges at Qmax are reported in the Box

7.2. Pdet@Qmax is the most significant value in the event of
micturition because it is used both to calculate the degree of
obstruction (BOOI) and the contractility of the detrusor
(BCI).
Footnote
There is an inevitable lag between recording of pressure

and flow, which corresponds to the time taken by the
urine to reach the flowmeter jar (typically less than 1 s).
This must be taken into account when measuring pres-
sure-flow relation. The lag is usually more consistent in

men who void in standing position than in women who
void sitting on the commode. To overcome the problem
in men, the funnel of the flowmeter can be approached
to the glans penis. This lag is usually adjusted during
calibration process of the UDS equipment, moving to
the left the flow curve for the time corresponding to the
measured lag.
The criteria to make a diagnosis of bladder outlet obstruc-

tion are different in men and women.
7.4.1.1 Bladder Outlet Obstruction in Men
The value of making a precise diagnosis of obstruction in

men comes from the assumption that the outcomes of surgery
to treat benign prostatic hyperplasia (BPH) and its conse-
quent LUTS are improved when obstruction can be
documented.
As recommended by ICS, the degree of obstruction can be
calculated by the bladder outlet obstruction index (BOOI)
(see Box 7.3). The bladder outlet obstruction index is calcu-
lated as Pdet@Qmax – 2Qmax. If the BOOI is greater than
40 cmH2O, then the patient is considered obstructed. A
BOOI value of 20–40 cmH2O is equivocal and a value less
than 20 cmH2O suggests detrusor underactivity rather than
obstruction.
Box 7.3: BOOI (bladder outlet obstruction index) = Pdet@

Qmax – 2Qmax
• >40: Obstructed
• between: 20–40 Equivocal
• <20: Unobstructed
Bladder contractility has also been defined by the ICS. The

bladder contractility index (BCI) is calculated as Pdet
Qmax + 5 Qmax (Box 7.4). BCI greater than 150 cmH2O
reveals good bladder contractility, 100–150 cmH2O indicates
normal contractility, and less than 100 cmH2O denotes
reduced contractility.
Alternatively, a bladder obstruction and bladder contrac-
tility nomogram may be used (see below). The BOOI and
BCI will be elevated in men with BPO and will be low in men
with detrusor underactivity.
Box 7.4: BCI (bladder contraction index) = Pdet @Qmax

+ 5 Qmax
• >150: Strong contractility

• between: 100–150 Normal contractility
• <100: Weak contractility
For a complete picture of voiding process, to the above

parameters is linked the voiding efficiency index (VEI)
according to the formula:
VEI = volume voided / total bladder capacity ´100
For total bladder capacity is intended the total volume

voided + the post-void residual.
Most of urodynamic equipments are provided with soft-
ware that reports BOOI and BCI automatically on voiding
nomograms of ICS or Schaefer.
The ICS nomogram (Fig. 7.21) provides three levels of
obstruction and three levels of contractility, while Schaefer
nomogram (Fig. 7.22) provides six levels of obstruction
(0–I = nonobstructed, II–III = equivocal, IV–VI = obstructed)
and six levels of contractility (including a type of severe
hypocontractility, vw). From a practical point of view, the two
nomograms are equivalent.
PRESSURE/ FLOW ANALYSIS-Male

ICS Nomograms
BOO Index: pdetMax-2Qmax

pdetQmax >40 obstructed
(cm H2O) 20-40 equivocal
<20 unobstructed
150 strong
normal obstructed
100 activity
equivocal
week BC Index: pdetMax+5Qmax
unobstructed
40
150 strong
20 100-150 normal activity
0
0 20 30 <100 weak
Qmax (ml/s)
Abrams P, 1999
Figure 7.21 ICS pressure-flow nomogram
SCHAEFER NOMOGRAM
25
N+ ST
N-
20
W+
Qmax (ml/s)
15
W-
10
5 0 I II III IV V VI
VW
0
0 20 40 60 80 100 120 140
Pdet (cmH20)
Figure 7.22 Schaefer pressure-flow nomogram

7.4.1.2 Bladder Outlet Obstruction in Women
The definitions and nomograms that are used to describe

BOO in men do not apply to women. Clearly, men and women
have unique micturitional characteristics. The causes of
obstruction in women vary from anatomic (pelvic prolapse,
iatrogenic obstruction after stress incontinence surgery) to
functional (dysfunctional voiding).
In females, mostly used is the Groutz and Blaivas
nomogram.
BOO is defined as a free Qmax < 12 ml/s combined with a
Pdet max of >20 cmH2O or evident radiographic obstruction
in the presence of a sustained detrusor contraction of
>20 cmH2O.
The choice of free Qmax and Pdet max instead of intubated
Qmax and Pdet@Qmax depends upon the difficulty in per-
forming uroflowmetry in women with a catheter in place and
the fact that free flowmetry is significantly higher without a
catheter. In addition, since there are no significant differences
between Pdet@Qmax and Pdet max, the latter value should be
preferred because it enables analysis also in patients incapable
of voiding.
The Groutz-Blaivas nomogram includes four zones to
classify the patients from unobstructed to severely obstructed
(Fig. 7.23).
The nomogram examines only the degree of obstruction,
so that detrusor contractility, in women, is not calculated. This
is a consistent limitation since detrusor underactivity is a fre-
quent condition in women, especially in old age. Some use the
male voiding nomograms, but their reliability is disputable
since women basically void in a different way from men.
The voiding mechanism in female is recognized as more
complex than that in men. In fact, women void via a variety
of mechanisms, including abdominal straining plus pelvic
floor relaxation, with or without a detrusor contraction.
Groutz-Blaivas female voiding nomogram

160
140 Severe obstruction (3)
120
pdet.Qmax (cmH2O)
100
80 Moderate obstruction (2)
60
40 Mild obstruction (1)
20
No obstruction (0)
0
0 10 20 30 40 50
Free Qmax (ml/s)
Figure 7.23 Groutz and Blaivas nomogram
Box 7.5: Normal Pressure Ranges at the End of Micturition

• Pves: 37–63 cmH2O
• Pabd: 24–34 cmH2O
• Pdet: 03–25 cmH2O
As at the beginning, even at the end of voiding process, it

is a good practice to verify the quality of recorded traces by
asking the patient to cough and check the pressure ranges in
the bladder and the abdomen to make sure there were no
artifacts during bladder emptying.
The normal pressure ranges are reported in the box 7.5.
Footnote
If at the end of micturition the value of Pdet is too high,
it may depend on the post-void residual. In the absence
of significant residual urine, artifacts in Pves and Pabd
should be ruled out.
7.4.2 Common Artifacts During Pressure-Flow

Study: Recognitions and Solutions
Artifacts are spurious and inaccurate urodynamic observa-
tions. Multichannel pressure-flow tracings may have an infinite
number of artifactual patterns. Their recognition is a part of
good urodynamic practice. Below are the most significant ones.
The ICS identified three criteria as minimum recommendations
for quality control of multichannel urodynamics. They include:
• Resting values for abdominal, intravesical, and detrusor
pressure should be in a typical range.
• The abdominal and intravesical pressure signals should be
“live,” with minor variations caused by breathing or talk-
ing being similar for both signals; these variations should
not appear in the detrusor pressure signal (Pdet).
• Coughs should be used (every 1 min or, e.g., 50-ml filled
volume) to ensure that the abdominal and intravesical
pressure signals respond equally. Coughs immediately
before voiding and immediately after voiding should be
also included.
Below are the most significant artifacts observed during
conventional urodynamics and the relative solutions:
Filling phase (cystometry)
• Abnormal resting pressure values (Fig. 7.24). Pressure
readings at the beginning of the test ensure that the
recorded pressures can be used later on for clinical
decision-making such as assessment of bladder compliance
and the presence or severity of bladder outlet obstruction.
Solution: external pressure transducers should be
zeroed again, lines flushed, and catheters repositioned.
• Incorrect zero pressure caused by setting to zero the pres-
sure following rather than prior to insertion of catheters in
the body. The connection of the patient to the recording
unit. In these conditions zeroing is performed at the blad-
der and rectal pressures instead of atmospheric pressure
(Fig. 7.25).
Solution: zeroing should be redone with patient
disconnected.
ABNORMAL RESTING PRESSURES

Pabd & Pves too low
Pressure
(cmH20)
Filling phase Voiding phase
Pabd
6
(range 32-44)
Pves
Pdet@Qmax lower than real
10
value *
(range 25-45)
Pdet
4
(range -1 -6) time (min)
* if Pdet @Qmax is lower nomograms may indicate voiding as equivocal instead obstructed
Figure 7.24 Abnormal resting pressure values
AUTOMATIC ZEROING WITH PATIENT CONNECTED TO RECORDING UNIT

100 zeroing
Pves (cmH20)
30 incorrect pressure value

0
100
Pabd (cmH20)
40 incorrect pressure value

0
100
incorrect pressure value

Pdet (cmH20)
0
-10 time (min)
Figure 7.25 Wrong zeroing. Zeroing is performed at the bladder

and rectal pressures instead of atmospheric pressure
• Mismatch of signals (Fig. 7.12).

Both Pves and Pabd should demonstrate a nearly mir-
ror image of recorded pressure. If the Pves and Pabd read-
ings do not follow each other, the examiner should be
aware that the pressures read by the transducers may not

reflect those within the bladder or the abdomen.
Accordingly Pdet = Pves-Pabd may be abnormally high or
abnormally low on coughing:
Pves is too high.
Cause: the line may be kinked or the vesical catheter
may have been displaced in the urethral
sphincter.
Solution: exclude kink and adjust the position of the
catheter.
Pves is too low.
Cause: the line may contain air bubbles or may leak
fluid or may be kinked.
Solution: check for kink and fluid leak or flush the
lines.
Pabd is too high.
Cause: misplacement of the rectal catheter against
the rectal wall, kinking of the line, excess of fluid
in the balloon.
Solution: exclude kink, reposition the catheter, and
drain few drops of fluid from the balloon.
Pabd is too low.
Cause: the line may contain air bubbles or may leak
fluid or may be kinked.
Solution: check for kink, fluid leak, or flush lines.
• Lost of “live” signal due to disconnection of the catheter
from transducer lines.
Solution: check the connections of the lines.
• Gradual rise of Pves signal due to progressive misplace-
ment of the catheter in the bladder neck.
Solution: repositioning of the catheter
RECTAL CONTRACTIONS
FILLING PHASE VOIDING PHASE

Pabd (cmH20)
Pves (cmH20)
Pdet (cmH20)
Flow (ml/s)
Time (min)
Figure 7.26 Filling recording showing rectal contractions. Rectal

contractions are seen frequently and defined as multiple fluctua-
tions in abdominal pressure of at least 5 cmH2O. Rectal contractions
should be recognized, but usually don’t interfere with the interpreta-
tion of the examen
• Gradual fall of Pabd and/or Pves signals due to fluid leak-

age in the system.
Solution: check the connections between transducers, lines,
and catheters. Flushing if necessary
• Negative fluctuations of Pdet due to physiological rectal
contractions (Fig. 7.26).
Solution: repositioning of the rectal catheter
Voiding phase
The most common artifact during voiding phase is the lost
of the line due to the displacement of vesical or rectal
catheter (Fig. 7.27).
Solution: the test should be repeated.
7.5 Pressure-Flow Study in Pediatric Age 121
CATHETER LOST DURING VOIDING
filling phase voiding phase

Pabd (cmH20)
Pves (cmH20)
Pdet (cmH20)
Flow (ml/s)
Figure 7.27 Pressure-flow recording showing displacement of the

rectal catheter. Cough immediately before and after voiding should
be included in the study to verify that the vesical and rectal catheters
are in place
7.5 Pressure-Flow Study in Pediatric Age

UDS in children may be invasive and traumatic. Understanding
the proper indications for such testing is crucial. UDS are
commonly used in three patient populations:
• Neurogenic bladder, mostly spinal dysraphism
• Posterior urethral valves
Children with spinal dysraphism typically demonstrate
one of three specific findings on UDS:
• Complete denervation of lower urinary tract with detrusor
areflexia with or without poor bladder compliance
• Detrusor overactivity with synergic urethral sphincter
• Detrusor overactivity with dyssynergic urethral sphincter
The most deleterious patterns are:

• A bladder-filling pressure >40 cmH2O
• A voiding or leaking pressure >80–100 cmH2O
Both are considered high risk for progressive bladder and
renal deterioration.
Dysfunctional voiding specifically refers to a child who
contracts the pelvic floor musculature during the act of voli-
tional voiding.
Clinical presentation usually includes recurrent UTI, uri-
nary hesitancy, or abnormal voiding patterns.
The condition can be usually diagnosed through a simple
uroflowmetry with perineal EMG surface electrodes and
does not require the UDS as formal part of investigation.
However, in the most severe cases (Hinman-Allen syndrome),
UDS with the addition of fluoroscopy (videourodynamics) is
recommended to assess the elevated detrusor storage pressures,
the presence of vesicoureteral reflux, and the behavior of ure-
thral sphincter during the active voiding.
Posterior urethral valves represent the most common
form of congenital obstruction of lower urinary tract in
infant male. UDS testing is generally accepted as the most
appropriate way to evaluate bladder function in these
patients. The most common UDS patterns in these children
are:
• Detrusor overactivity
• Reduced bladder compliance
• Impaired pelvic floor activity
UDS is usually employed for the first time between 9 and 12
months of age in children whose valves have been ablated in
infancy for a basic assessment of bladder physiology. Subsequent
testing is performed in the presence of recurrent UTI, high
residual urine, or new-onset hydroureteronephrosis.
While the overall UDS study is performed in the same
manner for both children and adults, there are significant dif-
ferences in bladder physiology in infant and childhood. These
7.5 Pressure-Flow Study in Pediatric Age 123
peculiarities should be kept in mind when performing and

interpreting the study in this age group.
7.5.1 Setup
Pediatric urodynamic studies are most efficiently performed

in a pediatric dedicated center where the care of children is
committed to a specially trained staff. Waiting rooms should
have a family relaxing atmosphere as the patient will often
be accompanied by multiple family members including
brothers.
The decision as to whether or not parents should be pres-
ent for the test varies from case to case basing on interfamily
relationships of each single patient.
Since a significant percentage of patients undergoing UDS
has a neurogenic bladder and reduced sensation, the place-
ment of the catheters is not a problem except for the pres-
ence of hard stools in the rectum. The administration of an
enema the morning of or the day before the study can help
with bowel cleansing and facilitates the insertion of rectal
catheter.
Conversely, in nonneurogenic patients dedicated nursing
may be required to convince the child to accept the place-
ment of urethral and rectal catheter and the application of
EMG surface electrodes. Needle electrodes are not recom-
mended in pediatric studies. In selected cases mild sedation
may be necessary to facilitate the study.
As children are frequently active and can exhibit artifac-
tual movement during study, a sensor system with sampling
rate of 1000 Hz is recommended.
Appropriate monitoring and notation during the study
assist the examiner in recognizing motion, talking, and crying
artifacts.
Smaller catheters such as 6-Fr dual lumen urethral cathe-
ter and 8-Fr rectal catheter are recommended for younger
children and infants.
7.5.2 Filling Phase
Bladder capacity is estimated according to age.

In infants, bladder capacity is calculated by the formula:
38 + ( 2.5 ´ age in months ) = bladder capacity in mL
In older children (>2 years of age), the most commonly uti-

lized formulas are
30 ´ ( age in years + 2 ) = bladder capacity in mL
Or
30 + ( age in years ´ 30 ) = bladder capacity in mL
The filling rate of normal saline or radiographic contrast is

usually 10 ml/min or better is calculated as 10 % of expected
bladder capacity.
In children some findings (detrusor overactivity, reduced
bladder capacity) may be present during the first filling but
absent during subsequent filling probably in consequence of
initial discomfort or anxiety. For that reason multiple cycles
of filling are recommended in children.
Bladder sensation is often an unreliable measure in chil-
dren except in cooperative subjects. Indirect signs that void-
ing is to occur may be the fidgeting or curling of the feet toes.
In neurogenic patients impaired bladder sensation is nor-
mal. Bladder should be filled slightly beyond the age-appro-
priate bladder capacity or to the volume at which the child
develops abdominal pain.
Bladder compliance is calculated in a way similar to that in
adults.
The generally accepted normal compliance in children is
defined by a less than 10 cmH2O pressure rise at the
expected age bladder capacity. More specifically compliance
can be calculated as 5 % of any individual bladder capacity

per cm H20.
Resting detrusor pressure exceeding 30 cmH2O during the
filling phase is considered at risk of upper urinary tract
damage.
7.5.3 Voiding Phase
Time and patience are often required to get children to mic-

turate during UDS study.
Normal voiding pressure ranges from 55 to 80 cmH2O in
boys and from 30 to 65 cmH2O in girls.
If voiding pressure rises above a mean of 118 cmH2O in
boys or 75 cmH2O in girls, a urethral obstruction should be
suspected. In these cases fluoroscopy is indicated to better
define the level of obstruction and better understand the
clinical scenario for the child.
In order to validate the emptying phase, voided volume in
children should be at a minimum of 100 ml or greater of 50 %
of the expected age bladder capacity.
Suggested Reading
Clement KD, Lapitan MC, Omar MI, Glazener CM (2013)
Urodynamic studies for management of urinary incontinence in
children and adults. Cochrane Database Syst Rev (10):CD003195
Clement KD, Burden H, Warren K et al (2015) Invasive urodynamic
studies for the management of lower urinary tract symptoms
(LUTS) in men with voiding dysfunction. Cochrane Database
Syst Rev (4):CD011179
Set-Up of the Patient

Gammie A, Clarkson B, Costantinou C, et al. International
Continence Society guidelines on urodynamic equipment perfor-
mance. Neurourol Urodyn. 2014;33:370–9.
Gammie A, Abrams P, Bevan W, et al. Simultaneous in vivo compari-

son of water-filled and air-filled pressure measurement catheters:
implications for good urodynamic practice. Neurourol Urodyn.
2015. doi:10.1002/nau.22827.
Hogan S, Jarvis P, Gammie A, Abrams P. Quality control in urody-
namics and the role of software support in the QC procedure.
Neurourol Urodyn. 2011;30:1557–64.
McLachlan LS, Rovner ES. Good urodynamic practice: keys to per-
forming a quality UDS study. Urol Clin North Am. 2014;41:363–73.
Rosier PF, Kirschner-Hermanns R, Svihra J, Homma Y, Wein AJ. ICS
teaching module: analysis of voiding pressure/flow analysis (basic
module). Neurourol Urodyn. 2016;35:36–8.
Filling Cystometry
Gray M. Traces: making sense of urodynamic testing-part 5: evaluation
of bladder filling/storage functions. Urol Nurs. 2011a;31:149–53.
Gray M. Traces: making sense of urodynamic testing-part 6: evalua-
tion of bladder filling/storage: bladder wall compliance and the
detrusor leak point pressure. Urol Nurs. 2011b;31:215–21.
tion of bladder filling/storage: evaluation of urethral sphincter
incompetence and stress urinary incontinence. Urol Nurs. 2011c;
31:266–77.
Gray M. Traces: making sense of urodynamic testing-part 8: evaluat-
ing sensations of bladder filling. Urol Nurs. 2011d;31:369–74.
tion of sensations detrusor response to bladder filling. Urol Nurs.
2012;32:21–8.
Pressure/Flow Study
tion of micturition via the voiding pressure/flow study. Urol Nurs.
2012a;32:71–8.
Gray M. Traces: making sense of urodynamic testing-part 11: quanti-
tative analysis of micturition via the voiding pressure/flow study:
pressure/flow nomograms. Urol Nurs. 2012b;32:159–65.
Nitti VW. Pressure flow urodynamic studies: the gold standard for
diagnosing bladder outlet obstruction. Rev Urol. 2005;7 Suppl
6:S14–21.
Rosier PF, Kirschner-Hermanns R, Svihra J, et al. ICS teaching mod-
ule: analysis of voiding, pressure flow analysis (basic module).
Neurourol Urodyn. 2016;35:36–8.
Pressure Flow Study in Pediatric Age

Drzewiecki BA, Bauer BS. Urodynamic testing in children: indica-
tions, technique, interpretation and significance. J Urol. 2011;186:
1190–7.
Ghanem MA, Wolffenbuttel KP, De Vylder A, Nijman RJ. Long-
term bladder dysfunction and renal function in boys with poste-
rior urethral valves based on urodynamic findings. J Urol. 2004;
171:2409–12.
Hoebeke P, Van Laecke E, Van Camp C, et al. One thousand videou-
rodynamic studies in children. BJU Int. 2001;87:575–80.
Koff SA. Evaluation and management of voiding disorders in chil-
dren. Urol Clin North Am. 1988;15:769–75.
Neveus T, von Gontard A, Hoebeke P, et al. The standardization of
terminology of lower urinary tract function in children and adoles-
cent: report from the Standardization Committee of International
Children’s Continence Society. J Urol. 2006;176:314–24.
Soygur T, Arikan N, Tokatli Z, Karaboga R. The role of video-
urodynamic studies in managing non-neurogenic voiding dys-
function in children. BJU Int. 2004;93:841–3.
Chapter 8
Electromyography of Pelvic
Floor Muscles
Electromyography (EMG) is a study of bioelectrical activity

of striated muscles.
The unit of measure is in microvolts (µV).
Pelvic floor muscle EMG is most commonly recorded as
part of urodynamic studies to obtain information about the
kinesiological behavior of pelvic floor structures during
filling and voiding.
According to AUA/SUFU guidelines on adult urodynamics,
EMG of pelvic floor muscles is recommended in patients
with relevant neurological disease at risk for neurogenic
bladder.
EMG may also be useful in the evaluation of neurologically
intact individuals with obstructive pressure-flow studies in
the absence of an anatomical obstruction (dysfunctional
voiding).
The study may be quantitative or qualitative:
• The quantitative EMG (kinesiological EMG) allows an
assessment of the state of relaxation or contraction of the
muscle investigated, and that is what is normally detected
with an equipment of urodynamics. For this type of
recording, surface electrodes are appropriate.
• The qualitative EMG (neurophysiological EMG) is the
recording of the action potentials of muscle cells
investigated through needle electrodes and recording
oscilloscope with sound recording. Its use is limited to

DOI 10.1007/978-3-319-33760-9_8,
130 Chapter 8. Electromyography of Pelvic Floor Muscles
cases of neurological injuries in which it is necessary to

assess the extent of denervation and reinnervation
phenomena.
8.1 Types of Electrodes and Setup

Three main types of electrodes for EMG measurement are
available (Fig. 8.1):
• Surface
• Needle
• Wire
Surface electrodes consist of small patches with shielded
cables or unshielded wires with reusable snaps.
The active plates are placed as close as possible to the anal
sphincter at 3 and 9 o’clock position, while the ground electrode
is usually placed in the medial aspect of the thigh (Fig. 8.2). The
wires are then fixed on symphysis pubis before their connection
with the recording device. Attempts should be made to avoid
any possible wetting of the electrodes during voiding.
Footnote 1
When surface electrodes are used, the skin should be
shaved and cleaned with abrasive paste prior to their
placement.
EMG Electrodes
a b c
surface needle wire
Figure 8.1 EMG electrodes (a) surface (b) needle (c) wire.
8.1 Types of Electrodes and Setup 131
Footnote 2
EMG activity is detected, for convenience, from the anal
sphincter. In fact, the anal sphincter, such as urethral
sphincter, is a part of pelvic floor musculature with
which shares both innervation and functional activity.
However, in cauda equina lesions as well as in the
peripheral nerves injuries, there should be a discrepancy
in behavior between the urethral sphincter and anal
sphincter, so it is preferable to detect activity directly
from the urethral sphincter by a needle electrode.
The major advantages of surface electrodes are their non-

invasiveness. The main drawback is that they use, by conven-
tion, perianal muscle activity as surrogate for urethral
sphincter activity. Several studies have demonstrated sepa-
rate innervation of levator ani and urethral sphincter. This
Neddle
Ground
electrodes
Surface
electrodes
Figure 8.2 Surface and needle electrodes placement. Ground is

usually placed on the buttock or medial aspect of the thigh
suggests that levator ani activity may not accurately reflect

urethral sphincter activity. This condition is the rule in sacral
neurologic lesions and in peripheral nerve lesions, in which it
is more appropriate to record electrical activity directly from
urethral sphincter.
Concentric needle electrodes consist of a hollow steel
needle within which there is a fine wire.
The potential difference between the outer and inner core
is measured while the patient is grounded with a separate
surface electrode. The electrodes record electrical activity
within 0.5-mm radius of the tip.
Concentric needles are placed into the periurethral
muscles near the urethral meatus in women and advanced
parallel for 1–2 cm (Fig. 8.3) into the bulbocavernous muscle
in men. Correct placement can be verified by an audio moni-
tor which will demonstrate a poppy noise that increases when
Right needle
electrode position
Figure 8.3 Needle electrode placement in female

the patient is asked to contract the muscles. The major limit

of needle electrodes is patient discomfort and limitation of
mobility during urodynamic testing to avoid their dislodge-
ment. The advantage is the possibility to analyze single-action
potentials through an oscilloscope monitor.
An alternative to concentric needle electrodes are the wire
electrodes which consist of platinum or copper wires with a
small hook on the tip which are inserted into the pelvic floor
using 25-gauge needles. Once inserted, the needle is with-
drawn leaving the hook within the musculature. Like concen-
tric needles, wire electrodes are placed into periurethral
muscles in female and in the bulbocavernous muscle in male.
Again, audio monitor is recommended while placing the
wires.
Once inserted, wire electrodes cannot be manipulated and
when necessary they must be removed and replaced. However
they permit a better movement of the patient during urody-
namic testing.
8.1.1 Checking the Correct Position

of the Electrodes
The correct position of the electrodes can be verified by
asking the patient to contract and release the anal sphincter:
the contraction results in an increase of activity, while
relaxation causes a reduction of the activity. The cough
(increased activity) can be used with the same purpose.
8.1.2 Common Artifacts
EMG is a technique full of artifacts. Artifacts are created by

electrical currents that are not generated by muscular activity.
Electrical noises that may affect the EMG signal can be
divided in:
• Technical noise (the most common source of artifacts)
including improper electrode placement and/or improper
grounding. This potential source of error can be minimized

by verifying proper insertion of electrodes through an
audio monitor or by asking the patient to cough or con-
tract the pelvic musculature.
The second most common technical artifact is the
voiding across surface EMG electrodes, which results in
an increase of EMG trace. This potential source of
error can be avoided or reduced by taping the lead
wires in unshielded patches or, preferably, using
shielded patches.
• Ambient noise.
The electromagnetic radiation may influence EMG
recording.
To avoid this effect, the room where usually EMG is per-
formed should be magnetically shielded. Another common
ambient noise is the 60-Hz signal (Fig. 8.4) generated by
room lighting, fluoroscopic generators, and electrosurgical
units that should be turned off during recording. To identify
the origin of noise, the examiner should attach an EMG patch
on this hand and verify each potential source.
• Physiologic artifacts.
Physiologic artifacts may also interfere with EMG
traces. The most common is the EMG signal generated
from the heart whose appearance is synchronous with
pulse rate.
Another modern source of artifacts is a sacral neuro-
modulation device. When on, it will interfere with EMG
signal, but when the device is turned off, the signal reverts
to normal.
60 HZ artefact
Figure 8.4 60-Hz artifact. Regular deflections resembling each

other with a frequency of 60/s
8.1.3 Normal EMG Activity During Micturition

Cycle
At the beginning the EMG signal is usually low. As the filling

proceeds, the signal slightly increases, a process called
recruitment or guarding reflex. During normal micturition,
EMG activity disappears completely few seconds before the
detrusor contraction starts. This is a coordinated response to
neuromodulation of pontine micturition center. The EMG
signal then resumes its activity once the bladder is empty
(Fig. 8.5). In neurologically normal individuals, EMG should
increase during cough, Valsalva maneuver, or volitional
contraction. In fact, not all patients may be able to recruit
their pelvic floor muscles when volitionally asked.
8.1.4 Abnormal EMG Patterns
Abnormal EMG pattern includes:

• Detrusor-external sphincter dyssynergia (DESD)
Normal EMG activity during micturition cycle

Max Cystometri Capacity
inf. vol (ml)
Pdet (cm H2O)
cough cough guarding reflex
EMG
Flow
Figure 8.5 EMG activity during micturition cycle. Normally EMG

activity increases during bladder filling and should be almost silent
during voiding (sphincter relaxation)
• Fowler syndrome
• Sphincter bradykinesia in Parkinson’s disease
8.2 DSD
Detrusor sphincter dyssynergia (DSD) is defined as lack of
coordination between detrusor and urethral sphincter during
voiding due to a neurological abnormality. It is commonly
seen in supraspinal cord lesions that interfere with
neuromodulation from pontine micturition center. If not
managed appropriately, DSD may have negative effects on
both the upper and lower urinary tract.
The diagnosis of DSD by EMG requires an elevated EMG
activity during detrusor contraction in the absence of Valsalva
and Credè maneuvers (Fig. 8.6).
EMG activity may be continuous or intermittent. Three types
of DSD have been identified depending on EMG findings:
DETRUSOR - SPHINCTER DYSSINERGIA
suprapubic taping
Pves (cmH2O)
Pabd (cmH2O)
Pdet (cmH2O)
EMG
time (min)
Figure 8.6 DSD Detrusor involuntary contraction with increased

EMG activity following lower abdomen taping
8.3 Fowler Syndrome 137
• Type 1: Characterized by a simultaneous increase of detru-

sor pressure and external sphincter EMG activity that
reaches its maximum at the peak of detrusor contraction.
At this point sudden complete external relaxation occurs
allowing urination.
• Type 2: Characterized by clonic contractions of the exter-
nal urethral sphincter scattered throughout detrusor
contraction. Patients usually void with an interrupted
stream.
• Type 3: Characterized by an external sphincter contrac-
tion persisting during the entire detrusor contraction.
These patients void with an obstructive stream or cannot
void at all (Fig. 8.7).
Complete lesions have usually either type 2 or 3 DSD, whereas

incomplete lesions are usually associated with type 1 DSD. Type 2
and 3 DSD are considered to have a greater risk of urological
complications due to the continuous high bladder pressure.
8.3 Fowler Syndrome

Fowler syndrome is a subgroup of dysfunctional voiding affect-
ing young women with recurrent episodes of urinary retention
and other endocrine problems resembling Stein-Leventhal syn-
Different types of DSD

Type I Type II Type III
Pdet (cmH2O)
EMG (uV)
Flow (ml/s)
Figure 8.7 DSD (a) type I (b) type II (c) type III (see text)
drome. Urinary retention is due to a primary abnormality of the

striated urethral sphincter characterized by complex and repeti-
tive EMG discharges. This abnormality prevents the relaxation
of the sphincter causing the inability to empty the bladder. The
gold standard for diagnosing the syndrome is the concentric
needle EMG of the external urethral sphincter. The pathogno-
monic finding is a pattern of decelerating bursts and complex
repetitive discharges. When heard over the audio output of
EMG machine, it is likened to the sound of helicopters (Fig. 8.8).
8.4 Dysfunctional Voiding

Dysfunctional voiding is characterized by an intermittent
and/or fluctuating flow rate due to intermittent contractions
of periurethral striated muscles or levator muscles during
voiding in neurological normal subjects. This type of voiding
may be the result also of the abdominal straining, but in this
Concentric needle EMG of external sphincter in Fowler syndrome
Figure 8.8 Fowler syndrome. Concentric needle electromyography

showing typical complex repetitive discharges. Amplification of the
burst shows a decelerating pattern
8.4 Dysfunctional Voiding 139
case the EMG activity is synchronous with the increase in

abdominal pressure.
It may present at any age. In young children it is often associ-
ated with urinary incontinence, nocturnal enuresis, or recurrent
urinary infection, while adults classically present with voiding
difficulty or pain. In children the disease has a wide spectrum of
presentations from innocuous to grave. In severe cases the con-
dition can present in a form virtually indistinguishable from
classical neurogenic bladder, and such patients may progress to
bilateral hydronephrosis and end-stage renal insufficiency
(Hinman-Allen nonneurogenic neurogenic bladder).
The diagnosis hinges on the repeated demonstration of a
staccato pattern on uroflow curve. When uroflowmetry is
combined with surface EMG, a sporadic increase-decrease of
EMG activity can be noted (Fig. 8.9).
In male dysfunctional voiding may be associated with chronic
abacterial prostatitis marked by a mixture of pain, urinary, and
ejaculatory symptoms with no uniformly effective therapy.
In female is a learned behavior in response to an adverse
event or condition. In some women, urinary patterns in adult-
hood may be the result of unrecognized childhood dysfunction.
DYSFUNCTIONAL VOIDING
EMG
(mV)
FLOW
(ml/s)
Time (s)
Figure 8.9 Dysfunctional voiding. Staccato pattern of uroflow curve

associated with sporadic increase-decrease of EMG activity
Also, abnormal sphincteric behavior is commoner in

women who had vesicoureteral reflux in childhood.
Training with pelvic floor physiotherapy and biofeedback
still represents the first-line treatment for functional voiding
dysfunction. In adults, in selected cases of recurrent urinary
retention, sacral neuromodulation demonstrated a satisfying
long-term efficacy.
8.5 Sphincter Bradykinesia in Parkinson’s

Disease
Electromyography is an important component in the urody-
namic study of patient with Parkinson’s disease. Sphincter
bradykinesia, defined as an involuntary increase in EMG
signal that persists through at least the initial part of the void-
ing process, is fairly common. Its recognition may be crucial
in defining bladder outlet obstruction and deciding for pros-
tate surgery (Fig. 8.10).
SPHINCTER BRADYKINESIA IN PARKINSON’S DISEASE
Inf vol, (ml) SD 350

100 FD 200
Pabd (cmH2O)
Pves (cmH2O)
Pdet (cmH2O)
EMG
Flow (ml/s) failure to relax
Time (min)
Figure 8.10 Sphincter bradykinesia in Parkinson’s disease. Delayed

decreasing of EMG activity during voiding phase
Suggested Reading
Enkc P, Vodusek DB (2006) Electromyography of pelvic floor mus-
cles. J Electromyogr Kinesiol 16:568–577
Gray M (2011) Traces: making sense of urodynamic testing-part 3:
electromyography of pelvic floor muscles. Urol Nurs 31:31–38
Keshwani N, McLean L (2015) State of the art review: intravaginal
probes for recording electromyography from the pelvic floor
muscles. Neurourol Urodyn 34:104–112
Kuo TL, Ng LG, Chapple CR (2015) Pelvic floor spasm as a cause of
pelvic floor dysfunction. Curr Opin Urol 25:311–316
Chapter 9
Urethral Profilometry
The urethral pressure profile (UPP) is a graph indicating the

intraluminal pressure along the length of the urethra from
the bladder neck to the external meatus in females and from
the bladder neck to bulbous urethra in males.
The urethral pressure profile is performed at rest as well
as during stress maneuvers. At rest, the UPP is measured with
a bladder filling at least one third of the capacity (approxi-
mately 200 ml). Under stress, the UPP is performed while the
patient performs repetitively (at least three times) the
Valsalva maneuver or coughing. In this way it evaluates the
coefficient of transmission of abdominal pressure to the
proximal urethra.
9.1 Terminology (Fig. 9.1)

• The urethral closure pressure profile is given by the sub-
traction of intravesical pressure from urethral pressure.
• Maximum urethral pressure is the maximum pressure of
measured profile.
• Maximum urethral closure pressure (MUCP) is the maxi-
mum difference between the urethral pressure and the
intravesical pressure.
• Functional profile length is the length of the urethra along
which the urethral pressure exceeds intravesical pressure.

DOI 10.1007/978-3-319-33760-9_9,
144 Chapter 9. Urethral Profilometry
Urethral Pressure Profile Measurements according to ICS
Maximum
Pura (cmH2O)
Urethral Maximum
Closing Urethral
Pressure Pressure
Functional Profile Length

Bladder
Total Profile Length
Pressure
Distance (cm)
Figure 9.1 Urethral profilometry measurements according to ICS
• Pressure “transmission” ration (% PTR) is the increment

in urethral pressure on stress as a percentage of the
simultaneously recorded increment in intravesical
pressure.
9.2 Method of Measurement

There are currently three methods of measuring urethral
pressure profile:
• Fluid perfusion technique or Brown-Wickham technique
• Microtip/fiberoptic catheters
• Air-charged balloon catheters
Water-perfused catheters measure the fluid pressure
needed to just open a closed urethra.
Microtip catheters measure a true hydrostatic pressure
and are very sensitive to rapid changes in pressure. The
catheters are fragile and expensive and the measurement
depends upon transducer orientation.
9.3 Technique 145
Table 9.1 Advantages and disadvantages of different methods of

measuring urethral pressure profile
Advantages Disadvantages
Fluid Cheap Slow response to pressure
perfusion variations
Less susceptible to
technique
movement artifacts
Microtip/ Responsive to rapid Expensive and fragile.
fiberoptic pressure changes Stiffness of the catheter
transducers may alter the record.
Record influenced by
catheter orientation
Balloon No orientation Expensive. Dilating effect
catheters dependance on the urethra
Air-filled balloon catheters measure the average variation

of hydrostatic pressure over the length of the balloon. The
ability of air-filled catheters to measure pressure circumfer-
entially is widely considered a main advantage over microtip
catheters.
Fiberoptic catheters have been utilized during invasive
cardiac monitoring but only recently applied to the study of
the function of lower urinary tract in women. A proposed
advantage of fiberoptic catheters is the relatively low cost
compared with microtip catheters, a better resistance with
everyday usage, and a circumferential measurement of the
pressure.
Table 9.1 indicates advantages and disadvantages of each
method.
9.3 Technique
Water profilometry (also known as Brown-Wickham method)
is still the most widely used method for urethral pressure
measurement. The pressure recorded is not the real
hydrostatic pressure, but the pressure of fluid necessary to
open a closed urethra.
A triple-lumen catheter is the most convenient for simul-

taneous measurement of bladder pressure (Pves) and ure-
thral pressure (Pura) as well as fluid infusion.
Pves channel is usually close to tip of the catheter, while
Pura channel is 5–6 cm distal to the tip. Separate orifice for
infusion can be located both close to the tip near Pves chan-
nel and 5–6 cm below near Pura channel.
UPP is most commonly performed in sitting position: how-
ever, it can virtually be performed in any position depending
on individual clinical requirements.
The initial setup is the same as in cystometry: the whole
circuit is made air-free and zeroing is performed in standard
fashion.
Footnote
With microtip or air-charged catheters, zeroing is per-
formed outside the patient.
The puller system is placed facing the introitus or the

penis, and the catheter is attached to it.
Bladder filling is initiated through the infusion
channel at a rate of 50 mL/min.
After a filling between 50 and 150 ml depending upon the
presence or absence of detrusor overactivity or poor compli-
ance, resting urethral pressure profile is recorded.
The infusion pump is slowed down to 2–6 ml/s and the
puller is started to pull at 2 mm/s
If puller is not available, the catheter can be pulled manually
each time by 5–10 mm, and each pull is market on the screen.
9.4 Reading the Curve

Rest UPP can be divided in three phases during which the three
traces (Pves, Pura, Pclo: Pura-Pves) behave in a specific way:
First phase (Fig. 9.2a):
9.4 Reading the Curve 147
Water Profilometry: sequential pressure events

a
Bladder neck
8:00 8:30
Bladder
Pura Pves
Urethra Pves
filling
Sphincter
Pura
Pclo
b
Bladder
8:00 8:30 9:00
Pura
Urethra Pves
Pves
filling
Sphincter Pura
Pclo
c
Bulbous urethra Bladder 8:00 8:30 9:00
Pura
Urethra Pves
Pves
filling
Sphincter
Pura
Pclo
Figure 9.2 Water Profilometry sequential pressure events. (a) With

Pura at the bladder neck, a pressure rise is recorded in the corre-
sponding line. In Pclo the pressure rise is lower due to subtraction of
Pves. (b) Pura hole is in the middle of urethra and the maximum
urethral pressure is recorded. Pclo shows a similar but lower
increase in pressure due to subtraction of Pves. (c) Pura hole if odd
out the sphincter and trace fall to zero. In female Pclo may become
negative since Pves is still on
• Pura begins to detect the pressure in the urethra, while

Pves is still in the bladder.
• Pura > Pves.
• Pclo < Pura.
Footnote
The rationale of recording bladder pressure simultane-
ously with the urethral pressure is that the withdrawn of
the catheter through the urethra may trigger a micturition
reflex that could change the values of urethral pressure.
Second phase (Fig. 9.2b):

• Pura is at the middle of the urethra, while Pves is still in
the bladder.
• Pura > Pves.
• Pclo < Pura.
Third phase (Fig. 9.2c):
• Pura is off the meatus in females or enters bulbous urethra
in males. Its value returns to zero in females and in males
to a value close to the initial one.
• Pves is still in the bladder.
• Pclo may become negative.
During the entire measurement, Pves line stays into the
bladder to verify the presence of synchronous detrusor
contractions.
9.5 Morphology of the Curve

Urethral pressure profile in men (Fig. 9.3) shows typically two
peaks: the pre-sphincter peak followed by the prostatic plateau
and then the sphincter peak. Pre-sphincter peak and prostatic
plateau tend to increase in bladder neck hypertrophy and pros-
tatic enlargement, while sphincter peak tends to decrease in
incontinence following prostatic surgery. An abnormally high
sphincter peak can be seen in some neurogenic patients and in
cases of dysfunctional voiding (“abacterial prostatitis”).
In women, urethral pressure profile tends to have a sym-
metrical “bell-shaped” curve (Fig. 9.4).
A low urethral pressure may denote intrinsic sphincteric
deficiency associated with stress urinary incontinence, while a
high urethral pressure may indicate a dysfunctional voiding
9.6 Normal Urethral Pressure Values 149
RESTING URETHRAL PRESSURE PROFILE IN MALE
external sphincter peak

Pura (cmH2O)
Maximum Maximum
Urethral Urethral
Closing Pressure
Pressure
prostatic bulbous & anterior urethra
plateau
bladder functinal length
pressure total length
Distance (cm)
Figure 9.3 Male resting urethral profile. The curve includes a pre-
sphincteric area with the bladder neck and prostatic plateau fol-
lowed by the sphincteric area which displays the maximum urethral
pressure
in bladder pain syndromes and is typical of Fowler

syndrome.
9.6 Normal Urethral Pressure Values

There are sex differences between men and women in the
range of normal urethral pressure values.
In women, MUCP and urethral length tend to decrease
with age (Fig. 9.5).
Footnote
A rough guide to MUCP in women is a value of 92
minus age (cm H2O) (Edwards and Malvern 1974).
RESTING URETHRAL PRESSURE PROFILE IN FEMALE
Pura
(cmH2O) Maximum
Urethral Maximum
Closing Urethral
Pressure Pressure
Functinal length
bladder
pressure Total length
Distance (cm)
Figure 9.4 Female resting urethral profile. The curve has a typical
“bell” shape with the maximum pressure in the middle of the urethra
Age Related MUCP

120
Maximum urethral closure pressure
100
80
(cmH2O)
60
40
20
20 30 40 50 60 70
Age (years)
Figure 9.5 Female MUCP decreases steadily with age

9.8 Stress Urethral Pressure Profile 151
In men, MUCP (usually at the external sphincter level)

does not significantly decrease with age, while urethral length
tends to increase due to prostate enlargement. Normal values
range from 70 to 110 cmH2O.
9.7 The Clinical Role of Rest Urethral

Pressure Profile
The role of urethral pressure profile at rest is still more
controversial.
There is some evidence that a low MUCP is associated
with a poor outcome of surgery in women for SUI.
In post-prostatectomy incontinence, there is a close asso-
ciation between a sphincter damage and the reduction in the
MUCP.
In patients requiring continent urinary diversion, a value
of MUCP greater than 50 cmH2O can guarantee a good
continence if a good volume-low pressure reservoir is
created.
Conversely, a very high MUCP (>150 cmH2O) is a com-
mon finding in patients with dysfunctional voiding (usually
associated with an interrupted flow curve). Notably, such high
MUCP can be observed in very anxious patients who are
voluntarily contracting the pelvic floor. To overcome this
artifact, the patient is encouraged to relax, and the resting
profile is repeated. In case of different readings, the one with
lower MUCP is chosen as representative of the real condition
of the patient.
9.8 Stress Urethral Pressure Profile

Stress urethral profile is done mostly in women, to assess the
urethral competence during stress conditions such as cough-
ing or abdominal straining. It is unreliable in the assessment
of the functional urethral length which is falsely elongated by
the reduced pulling speed of the catheter.
STRESS URETHRAL PRESSURE PROFILE IN FEMALE

cough cough cough
cmH2O
Pclo
Pura
Pves % PTR
Distance (cm)
Figure 9.6 Diagram of female stress urethral pressure profile
Technique
The catheter is gently withdrawn at a rate of 1 mm per
second and the patient is asked to cough at 2-mm inter-
vals (at least four times).
In normal women, increases in abdominal pressure during
coughing are transmitted to the proximal three quarters
of the urethra with urethral pressures exceeding intravesi-
cal pressures. The lack of such pressure transmission to
the urethra indicates a defective urethral support (Fig. 9.6).
Pressure transmission can be calculated by the formula

% PTR = urethral pressure rise during stress maneuvers/
intravesical pressure rise ×100.
The calculation is available in various UDS software as an
automatic function or it can be performed manually.
% PTR decreases progressively from the bladder neck to
the external meatus (Fig. 9.7), and it is estimated that a
PTR of less than 90 % in the proximal three quarters of
the urethra is indicative of defective urethral support.
PTR is not widely utilized in clinical practice.
Pressure Transmission Rate along the Urethra

100
(cmH2O)
PTR
0
Distance (cm)
Figure 9.7 Diagram of % transmission rate. Transmission rate

decreases progressively from the bladder neck to the external
meatus
Suggested Reading
Anding R, Rosier P, Smith P et al (2016) When should video be
added to conventional urodynamics in adults and ii it justified by
evidence? ICI-RS 2014. Neurourol Urodyn 35:324–329
Bauer SB, Nijman RJM, Drzewiecki BA et al (2015) International
Children’s Continence Society standardization report on urody-
namic studies of the lower urinary tract in children. Neurourol
Urodyn 34:640–647
Dubbelman YD, Bosch JL (2013) Urethral sphincter function before
and after radical prostatectomy. Systematic review of the prog-
nostic value of various assessment techniques. Neurourol Urodyn
32:957–963
Edwards L, Malvern J (1974) The urethral pressure profile: theoreti-
cal consideration and clinical application. Br J Urol 46:325–335
Gray M (2012) Traces: making sense of urodynamic testing-part 12:
videourodynamics testing. Urol Nurs 32:193–202
Hsiang C, Chi-Shun L, Hsi-Chin W et al (2013) Remote monitoring
of videourodynamics using smartphone and free instant messag-
ing software. Neurourol Urodyn 32:1064–1067
Khullar V, Cardozo L (1998) The urethra (UPP, MUPP, instability, LPP).

Eur Urol 34(Suppl 1):20–22
Lemack JE (2004) Urodynamic assessment of patients with stress
incontinence: how effective are urethral pressure profilometry
and abdominal leak point pressures at case selection and predict-
ing outcome. Curr Opin Urol 14:307–311
Lemack JE (2007) Use of urodynamics prior to surgery for urinary
incontinence: how helpful is preoperative testing? In J Urol 23:
142–147
Mahfouz W, Al Afraa T, Campeau L, Corcos J (2012) Normal urody-
namic parameters in women: part II-invasive urodynamics. Int
Urogynecol J 23:269–277
Marks BK, Goldman HB (2014) Videourodynamics: indications and
technique. Urol Clin North Am 41:383–391
Porru D, Usai E (1994) Orthotopic ileal bladder substitute after radical
cystectomy: urodynamic features. Neurourol Urodyn 13:255–260
Trowbridge ER, Wei JT, Fenner DE et al (2007) Effects of aging on
lower urinary tract and pelvic floor function in nulliparous
women. Obstet Gynecol 109:715–720
Chapter 10
Videourodynamics (VUDS)
Videourodynamic studies consist of the simultaneous

measurement of multichannel urodynamic parameters with
imaging (fluoroscopy) of the lower urinary tract (Fig. 10.1). The
technique is the most sophisticated investigation of lower uri-
nary tract since it provides a precise evaluation of both anatomy
and function. Fluoroscopy allows direct observation of the
bladder outline, the position and conformation of the bladder
neck in relation to the pubic symphysis, bladder neck closure
during rest and stress, and vesicoureteric reflux during filling and
voiding. Most of the equipments commercially available are
provided with softwares that correlate fluoroscopic images with
the corresponding urodynamic parameters such that reports
have the images simultaneously with the pressure tracings.
Videourodynamics requires the X-ray facilities and is usu-
ally performed in a radiology department. The fluid medium is
radiographic contrast such as iohexol (Omnipaque), while the
technique of the examination follows the same rules (setting,
signal verification, etc.) of conventional urodynamics.
10.1 Procedure
UDS is performed in the usual manner and fluoroscopy is
done periodically both during filling and voiding phase.
Patient may be either supine on X-ray table or in a sitting

DOI 10.1007/978-3-319-33760-9_10,
156 Chapter 10. Videourodynamics (VUDS)
Inf.volume
X-ray monitor
Saline/contrast
medium
Pves
Pdet
Pabd
EMG
Flowmeter
Flow rate
Figure 10.1 Videourodynamic setup
position with C-arm fluoroscopic unit placed under vid-

eoUDS chair (Fig. 10.2).
During filling phase, X-ray intends on the bladder perpen-
dicularly in AP direction. If reflux is suspected, some oblique
views should be taken in order to visualize vesicoureteral
junction.
10.1 Procedure 157
Figure 10.2 Electrical bed with fluoroscopy C-arm particularly suit-

able for patients with neurogenic bladder (Courtesy of Sonesta
Medical)
Footnote
When radiological facilities and videoUDS chair are
unavailable together, conventional urodynamics and
videocystouretrography (VCUG) can be done sepa-
rately within a short interval.
Study done in AP position leads to superimposition of pre-

prostatic urethra in male and most or all of the urethra in
female depending on status of pelvic support and urethral
mobility. An initial plain film should be taken to confirm the
desired patient position.
During voiding phase, oblique views are preferable to
visualize the status of the bladder neck in males and the
whole urethra in females.
After the bladder is partially filled with radiographic con-

trast (usually 200 ml), a resting image is obtained. This image
provides informations on bladder position at rest, bladder
shape and outline, bladder neck at rest (open or closed), and
other abnormalities such as reflux or bladder diverticula.
Once the rest image is acquired, a strain (Valsalva) or
cough image is obtained.
During straining, bladder neck competence and any asso-
ciated incontinence (abdominal leak point pressure) and the
degree of bladder descent (cystocele) can be assessed.
When the bladder is filled to capacity, a voiding cystoure-
throgram (VCUG) is performed with previous assessment of
proper signal recording. When the patient is supine on the
X-ray table, he should be positioned such that a lateral image
is obtained.
During voiding phase, appropriate bladder neck and exter-
nal sphincter relaxation and whole urethral outline are
observed. Finally, a post-void image is obtained to determine
bladder emptying.
Footnote
When post-void residual is not a concern, this image
may be omitted to reduce radiation exposure. Post-void
residual can be accurately calculated from the volume
of contrast instilled and the volume voided.
10.2 Indications for the Addition of Video

to Conventional Urodynamics
In a broader context, VUDS has been advocated in situations
in which UDS alone fails to provide sufficient diagnostic
information to guide therapy, especially in patients with com-
plex or recurrent problems and patients with LUTD and
relevant neurological disease (NLUTD).
Recently, there has been a reappraisal of the role of VUDS
particularly in nonneurogenic LUTD.
10.2 Indications for the Addition of Video 159
Most of scientific societies acknowledge the role of VUDS

in neurogenic bladder.
In patients with spinal dysraphism (SD) or spinal cord
injury (SCI), the level of the lesion is not always predictive
for urinary dysfunction, in particular in patients with incom-
plete lesions.
VUDS may add information with the premise of improv-
ing management and follow-up.
However, there is only low-grade evidence for the added value
of VUDS in nonneurogenic LUTD. Some studies in nonneuro-
genic LUTS suggest a benefit of the added video, but objective
outcome analyses based on image-guided management are lack-
ing. Published evidence fails to determine the roles of the visual
information “versus” the UDS information gained at VUDS.
Classically, indications for VUDS include:
• Neurogenic bladder
• Female SUI
• BOO in females
• PBNO in young males
• Neurogenic bladder (NGB)
10.2.1 Tailoring VUDS for Neurogenic Patients
Many patients with NGB have significant limitations in their

mobility that do not allow them to sit in the urodynamic bed
like a typical patient. In addition, since many patients do not
void usually into a toilet, it is acceptable for neurogenic
patients to be in the supine position for urodynamic testing.
When performing videourodynamics, it is ideal for the patient
to be placed in oblique position to allow a better visualization of
the bladder neck. With patient in supine position, voiding record-
ing may be a problem. A wide-bore drain pipe with appropriate
length to reach the flowmeter may be necessary.
Filling Phase
Filling phase should assess the presence of vesicoureteral

reflux and the compliance of the bladder.
VUDS IN MYELOMENINGOCELE
Pabd
Pves
Pdet
Flow
Voiding by straining activate a complete reflux on the right
Figure 10.3 Videourodynamics in myelomeningocele. Bladder exhib-

its a “Christmas tree” appearance with multiple trabeculations, blad-
der neck open at rest, and Grade I vesicoureteral reflux. Voiding shows
a mild to moderate dilatation of ureter and renal pelvis (Grade III)
Footnote
When reflux occurs at low volume, it may go unnoticed
without the use of fluoroscopy.
A “Christmas tree” appearance with severe trabeculations

is often associated with high filling pressure (>40 cm H2O),
poor compliance (<30–40 ml/cmH2O), and high detrusor leak
point pressure (>40 cmH2O) that are signs of “unsafe blad-
der” prone to upper tract damage (Fig. 10.3).
Voiding Phase
During voiding phase, abnormal urethral images are seen during

detrusor contraction indicating both an insufficient opening
(less than 3 mm in diameter) of the bladder neck (detrusor-
bladder neck dyssynergia) and the external sphincter (detrusor-
sphincter dyssynergia). In the latter case, a wide opening of the
bladder neck ending in a narrowing (less than 3 mm in diameter)
of the external sphincter area is usually observed. Autonomic
dysreflexia (AD) can be a serious problems during VUDS in
spinal cord-injured patients.
Autonomic dysreflexia can be a serious problems during

VUDS in spinal cord -injured patients.
Autonomic dysreflexia is the only emergency in urody-
namic testing (Box 10.1).
Autonomic dysreflexia is a serious cardiovascular event
triggered by filling of the bladder.
AD occurs in approximately 60 % of cervical and 20 % of
thoracic of spinal cord-injured patients.
The symptoms are hypertension, throbbing headache,
sweating to the above the level of injury, palpitations, stuffy
nose, wheezing, abnormal vision, and marked anxiety.
The bladder must be emptied immediately, the patient
should be placed in a sitting position, and, under pressure
monitoring, 10 mg of sublingual nifedipine (Adalat) should be
administered. For optimal and faster absorption, the patient
should be asked to chew and swallow the medication.
In consequence of bladder emptying and drug, the pres-
sure may drop significantly, for which the patient should
again be placed in supine position with lower limbs raised,
and it may be necessary to administer intravenous fluids with
antishock medications.
The autonomic dysreflexia is the only emergency in urody-
namics and the anesthesia care is strongly recommended in
such patients.
During UDS study in spinal cord-injured patients, it is
generally recommended to obtain a baseline BP followed by
repeated measurements during the study.
If patients have a history of AD, a pharmacological pro-
phylaxis with 5 mg of terazosin 30 min or the night before the
examen would be appropriate.
Box 10.1: Autonomic Dysreflexia
• This is an emergency!
– Lesions above T6.
– Abnormal sympathetic response resulting from
stimuli below the level of lesion (i.e., catheter-
ization, bladder filling).
– Symptoms:
• Headache
• Hypertension
• Flushing/sweating of face/body above lesion
• Bradycardia
– Treatment:
• Find and reverse precipitating stimulus
(empty the bladder, remove catheter)
• Nifedipine 10–20 mg orally.
• Warning: significant pressure drop!
• Place the patient in supine position with
lower limbs raised.
• In case, administer intravenous fluid with
antishock medications.
– Prophylaxis:
• Procedure done with anesthesia monitoring
10.2.2 Female Urinary Incontinence
In the past videourodynamics was considered a basic tool in

the work-up of urinary incontinence associated with pelvic
organ prolapse. Under fluoroscopy the urethra and bladder
neck are observed during filling phase looking specifically for
their position in relation to the pubic symphysis. Furthermore
during stress maneuvers (straining and coughing) at 200 ml of
filling, the bladder neck and urethra are evaluated for open-
ing and leakage.
Footnote
Patients with symptoms of mild stress incontinence that
is not demonstrated by physical examination can have
their diagnosis confirmed by VUDS since even a small
amount of leakage can be detected with fluoroscopy.
Blaivas and Olsson in 1988 proposed a renowned classifi-

cation of SUI based on position of bladder base in relation to
the inferior margin of the pubic symphysis (IMPS) and
whether or not the BN is open at rest (Fig. 10.4):
Olsson-Blaivas classification of female SUI
Type 1: <2m descent
Type 2a: rotational descent/ cystocele

2b : abnormally low resting
position
Type 3: intrinsic sphincteric deficiency
Figure 10.4 Olsson-Blaivas classification of female SUI (see text)

• Type 1: Fluoroscopically visible urinary leakage with

coughing or straining associated with minimal urethral
hypermobility (<2 cm). BN closed at rest.
• Type 2: Marked rotational descent of the urethra with
coughing or straining, so that the internal meatus was at or
below the level of the external meatus associated with
fluoroscopically visible urinary loss
• Type 2b: Abnormally low position of bladder base at rest
with BN closed
• Type 3: Incontinence associated with no or very low urethral
hypermobility with cough or straining and BN open at rest
This classification is no longer followed in clinical practice,
and imaging doesn’t seem to add significant improvements to
pressure measurements of conventional urodynamics. The
International Consultation on Incontinence (ICI) considers
VUDS as a reasonable option in the preoperative evaluation
of complicated or recurrent female urinary incontinence
(Grade C recommendation).
10.2.3 Bladder Outlet Obstruction in Women

VUDS is an easy and practical way to diagnose bladder out-
let obstruction in women. Pressure/flow criteria for the
assessment of BOO in women are poorly defined.
Radiographic evidence of obstruction between the bladder
neck and distal urethra in the presence of sustained detrusor
contraction may be a valid alternative to conventional urody-
namics. In addition the site of obstruction is clearly visible.
10.2.4 Primary Bladder Neck Obstruction

in Young Male
Primary bladder neck obstruction (PBNO) is a condition in
which the bladder neck does not open appropriately or com-
pletely during voiding. The precise cause has not been eluci-
dated. One of the most accepted theories describes inefficient
bladder neck opening as a result of abnormal morphologic
arrangement of the detrusor/trigonal musculature. In younger
men (under 45 years) with chronic voiding dysfunction
VUDS in Bladder neck obstruction and Dysfunctional voiding

- Pdet (cmcH2O)
EMG
Flow (ml/s)
Figure 10.5 Videourodynamics in PBNO (a) and dysfunctional

voiding (b) in male
incidence of PBNO is about 50 %. Many patients with PBNO

are misdiagnosed as having chronic nonbacterial prostatitis
and treated with antibiotics with variable success.
Some cases, however, of apparent bladder neck dysfunc-
tion may actually be the result of abnormalities of the striated
urethral sphincter with dysfunctional voiding which share
symptoms and natural history.
PBNO is a videourodynamic diagnosis, the hallmark of
which is relative high-pressure, low-flow voiding with
radiographic evidence of obstruction at the bladder neck
with relaxation of the striated sphincter and no evidence of
distal obstruction (Fig. 10.5).
In comparison dysfunctional voiding shows a bladder neck
widely open with a sphincteric area tight due to poor relax-
ation of the striated muscolature.
It should be said, however, that when the bladder pressure
is low, inefficient bladder neck opening may be a conse-
quence of a detrusor underactivity.
Treatment options include pharmacotherapy with alpha-
blockers and surgical intervention.
PBNO can be treated surgically with unilateral or bilateral
transurethral incision of the bladder neck. Bladder neck inci-
sion without pinpoint diagnosis, i.e., in dysfunctional voiding,
will not only be ineffective but will be at risk of worsening the
symptoms.
In addition, the main concern with bladder neck incision is the
development of postoperative retrograde ejaculation, less likely
to occur with unilateral incision as opposed to bilateral incision.
Obviously, in the absence of a successful outcome, this side

effect could represent an additional serious problem for the
patient.
10.3 Disadvantages of Fluoroscopy

As with all radiographic studies, a disadvantage of fluoros-
copy for both patient and operator is radiation exposure.
The generally accepted premise is to have strict adherence
to the “a slow as reasonably achievable” (ALARA) principle
when performing the examen.
Several studies have shown that during VUDS, patients
are exposed to relatively small amounts of radiation. The
radiation exposure ranges from 2 mGy (less than an average
VCUG) to 10 mGy.
Since radiation dose is directly proportional to the time of
exposure and to the number of exposures, exposure time can
be minimized by using short burst of fluoroscopy and using
the last image feature.
10.4 Critical Reappraisal

of Videourodynamics
The role of videourodynamics has been recently reviewed by
ICI-RS.
Current guidelines do not indicate a specific improving value
of imaging to conventional urodynamics. Recommendations
are mostly based on single-center studies and expert opinion. In
particular, standardization of imaging protocols is not available,
and evidence regarding the balance between the utilized tech-
nique (number and timing of pictures, patient positioning, and
exposure time) and subsequent diagnosis is scarce. According
to expert consensus, VUDS seems relevant in the follow-up of
patients with spinal dysraphism, while the value of VUDS in
nonneurogenic lower urinary tract dysfunction is less than opti-
mal. In addition, VUDS does not seem necessary in uncompli-
cated female SUI, but it might improve the evaluation of
patients with recurrent SUI.
Suggested Reading
Anding R, Rosier P, Smith P et al (2016) When should video be
added to conventional urodynamics in adults and is it justified by
evidence? ICI-RS 2014. Neurourol Urodyn 35:324–329
Anding R, Smith P, De Jong T et al (2016) When should video and
EMG be added to urodynamics in children with lower urinary
tract dysfunction and is this justified by the evidence? ICI-RS
2014. Neurourol Urodyn 35:331–335
Giarenis I, Phillips J, Mastoroudes H et al (2013) Radiation exposure
during videourodynamics in women. Int Urogynecol J
24:1547–1551
Gray M (2012) Traces: making sense of urodynamics testing – part
12. Videourodynamics testing. Urol Nurs 4:193–202
Hsi RS, Dearn J, Dean M et al (2013) Effective and organ specific
radiation doses from videourodynamics ion children. J Urol
190:1364–1369
Marks BH, Goldman HB (2014) Videourodynamics: indications and
technique. Urol Clin North Am 3:383–391
Spinoit AF, Decalf V, Ragolle I et al (2016) Urodynamic studies in
children: standardized transurethral video-urodynamic evalua-
tion. J Pediatr Urol 12:67–68
Chapter 11
Ambulatory Urodynamics
Conventional urodynamics is a “nonphysiological” test, since

it involves a retrograde rapid filling of the bladder in a labo-
ratory setting which does not always allow a reliable repro-
duction of patient symptoms.
Conversely, ambulatory urodynamic monitoring (AUM)
analyzes the bladder and urethral function in the condition of
everyday life.
The ICS defines AUM as “any functional test of the lower
urinary tract predominantly utilizing natural filling the
urinary tract and reproducing subject’s normal activity.”
The main differences of AUM from conventional urody-
namics can be summarized as follows:
• The study is performed over a longer period of time,
usually 4 h, and allows more than one cycle of bladder fill-
ing and voiding.
• It utilizes a natural bladder filling (a standard fluid intake
of 200 ml half-hourly is recommended).
• It takes place outside the urodynamic laboratory.
• Normal activities of daily living (specific maneuvers to
provoke detrusor overactivity or incontinence are sug-
gested) are reproduced more easily.
AUM has a specific indication in those cases in which con-
ventional urodynamics fail to clarify the patient complaints
providing a second-line investigational modality to standard
urodynamic methods.

DOI 10.1007/978-3-319-33760-9_11,
170 Chapter 11. Ambulatory Urodynamics
11.1 Equipment
The equipment of AUM has been miniaturized over the years
and with the advent of air-charged catheters the recording
has become easier. The system includes:
• The recording unit
• The event sensors (pressure, EMG, leakage)
• A uroflowmeter
• A desktop/laptop computer
• Software to download and analyze the recorded data
The recording unit must be lightweight and portable to
allow freedom of movement. It should have a facility to mark
events on the traces to allow a better interpretation of the
recordings (Fig 11.1).
In any case, a bladder diary written by the patient should
always be recommended during test.
The recorder should have the ability to be connected to a
uroflowmeter, preferably by a wireless technology, to allow
simultaneous recording of pressure and flow.
Pressure transducers are usually solid-state 7-Fr bladder
and rectal catheters. Recently air-charged catheters have
been introduced. The advantage of these catheters over the
fluid-filled type is that they are at less risk of movement arti-
facts and don’t need adjustment of reference point.
All catheters must be “zeroed” at atmospheric pressure
before the insertion. Secure fixation is essential.
EMG is preferably a perineal integrated surface EMG.
Leakage can be detected in many ways – simply patient’s
perception, electronic nappy, urethral pressure measurement,
and urethral electrical conductance. None of these methods
are foolproof.
11.2 Technique
The setup is not dissimilar to that of conventional study.
Once the catheters are secured in place, they are con-
nected to the recorder which is worn on body in a pouch.
11.2 Technique 171
Figure 11.1 Wireless Bluetooth AUM unit (Courtesy of MMS)
Footnote
The Bluetooth technology allowed the use of wireless
catheters that greatly facilitate the examination.
AMBULATORY URODYNAMICS COMPRESSED TRACINGS

Pabd
Pves
EMG
Pdet
Events walking urgency leak urgency toilet
Figure 11.2 Ambulatory urodynamic compressed tracings
The patient is instructed to mark events in real time and fill

at the same time a bladder diary. He/she is asked to move
around in the hospital and do some specific activities including:
• Sitting on a chair
• Moving around the hospital
• Drinking
• Performing maneuvers which increase the abdominal
pressure (e.g., coughing, straining, lifting weight, climbing
stairs, etc.)
The patient is then asked to return to lab whenever they wish
to urinate. The recording unit is connected to the uroflowmeter
(if the uroflowmeter is wireless, this step is omitted) and syn-
chronized recording of pressure flow is taken.
At the end of the test, the recording system is connected to
the computer for the visualization of the collected data
(Fig. 11.2). Many manufactures provide the facility of AUM
software compatible with their office UDS machines. The
memory of the recording unit is digital allowing both com-
pression and expansion of the trace (Fig. 11.3).
11.3 Clinical Relevance of AUM 173
AMBULATORY URODYNAMICS DECOMPRESSED TRACING

Pabd
Pves
EMG
Pdet
events urgency urgency/leak urgency
Figure 11.3 Ambulatory urodynamic decompressed tracings: urgency

is associated with detrusor overactivity responsible for a leakage episode
During download, it is important for the patient to be pres-

ent in order to refer about diary notes and event markers.
The procedure is usually well tolerated.
11.3 Clinical Relevance of AUM

Ambulatory urodynamic studies were standardized in 2000
but have yet to be clinically validated.
In particular, AUM has been observed to have an increased
detection of detrusor overactivity.
Footnote
Conventional urodynamics fail to demonstrate a detru-
sor overactivity in 50–60 % of patients with urgency.
Furthermore, rapid filling used in conventional UDS could

elicit artifacts that do not manifest themselves during ambu-
latory UDS. However, the fact that AUM shows abnormali-
ties, especially detrusor overactivity, in healthy volunteers

decreases its specificity as a diagnostic test.
In addition, ambulatory UDS technique seems to be more
sensitive in recording pressure-flow changes than conven-
tional urodynamic measurements, which are currently the
gold standard in urodynamics. However, technical difficulties
occur in a substantial number of testing including:
• Lost of bladder line
• Poor subtraction between abdominal pressure trace and
vesical pressure trace
• Inability to void during the test
Furthermore, traces are more commonly harder to inter-
pret than with conventional urodynamics.
All these factors make its validation a complex task.
Nonetheless, it remains a necessary step when conven-
tional urodynamics is inconclusive, since it may be helpful in
diagnosing the cause of the symptoms and guiding more
appropriate management of patients.
Suggested Reading
Rademakers KL, Drossaerts JM, Rahnama’i MS, vanKoeveringe GA
(2015) Differentiation of lower urinary tract dysfunction: the role
of ambulatory urodynamic monitoring. Int J Urol 22:503–507
van Koeveringe GA, Rahnama’i MS, Berghmans BC (2010) The
additional value of ambulatory urodynamic measurements com-
pared with conventional urodynamic measurements. BJU Int
105:508–513
van Waalwijk DE, Anders K, Khullar V, Kulseng-Hanssen S, Pesce F,
Robertson A, Rosario D, Schafer W (2000) Standardisation of
ambulatory urodynamic monitoring: report of the Standardisation
Sub-Committee of the International Continence Society for
Ambulatory Urodynamic Studies. Neurourol Urodyn 19:113–125
Chapter 12
Urodynamics of the Upper
Urinary Tract
Urodynamics of upper urinary tract is often synonymous

with the assessment of upper urinary tract dilatation without
apparent cause of obstruction.
Hydronephrosis and hydroureter are quite common clinical
conditions.
Hydronephrosis is defined as distention of the renal caly-
ces and pelvis as a result of obstruction of the outflow of
urine distal to the renal pelvis. Analogously, hydroureter is
defined as a dilation of the ureter.
The etiology and presentation of hydronephrosis and/or
hydroureter in adults differ from that in neonates and children.
Anatomic abnormalities (including urethral valves or stricture
at the ureterovesical or ureteropelvic junction) account for the
majority of cases in children. In comparison, calculi are most
common in adults, while prostatic hypertrophy or carcinoma,
retroperitoneal or pelvic, are the primary causes in older
patients. Hydronephrosis or hydroureter is a normal finding in
pregnant women. The renal pelvises and calyceal systems may
be dilated as a result of progesterone effects and mechanical
compression of the ureters at the pelvic brim.
Early diagnosis of obstruction is important because most
cases can be corrected and a delay in therapy can lead to
irreversible renal injury.
However, dilatation does not always equate with obstruc-
tion since poor drainage of the urine may be a consequence
of an intrinsic problem of the pyeloureteral wall.

DOI 10.1007/978-3-319-33760-9_12,
176 Chapter 12. Urodynamics of the Upper Urinary Tract
12.1 Physiology of Urine Transport

Ureters actively convey urine from the kidney to the bladder.
This process is performed by two major mechanisms: the active
one (physiologic) resulting from contractile activity of the
smooth muscles in the wall of pyelo-ureteral system, and pas-
sive flow driven by hydrostatic pressure (pathologic) (Fig. 12.1).
The coordinated muscular contractions propagating along
the ureter and providing the active mechanism of urine trans-
port have been generally termed as “ureteral peristalsis.”
Contractions of smooth muscles within upper urinary tract
are evoked by action potential activity in atypical smooth
muscle cells termed pacemaker cells or ICC-like cells (inter-
stitial cells of Cajal). Produced urine is arranged into a bolus
that is propelled to the bladder by peristaltic waves occurring
from two to six times per minute. Baseline or resting ureteral
pressure ranges from 0 to 5 cm H2O, and superimposed ure-
teral contractions range from 20 to 80 cmH2O.
With increasing urine flow rate, the initial response of the
ureter is to increase peristaltic frequency. After the maximal
frequency is achieved, further increases in urine transport
occur by increase in bolus volume. As the flow rate continues
to increase, several of the bolus coalesce and finally the ure-
ter becomes filled with a column of fluid and dilates.
In addition to an increase in fluid input, ureteral dilatation
can occur also from a decrease in fluid output secondary to
an obstruction where due to the abnormally high resistance
to flow, the bolus is pushed back by the contraction wave.
Finally, the relation between ureteral intraluminal pres-
sure and intravesical pressure plays a pivotal role in deter-
mining the efficacy of urine passage across the UVJ into the
bladder. During filling the normal bladder maintains a rela-
tively low intravesical pressure that facilitates the transport
of urine across the UVJ and prevents ureteral dilatation. The
ureter has been shown to decompensate when sustained
intravesical pressure due to poor bladder compliance
approaches 40 cmH2O.
12.1 Physiology of Urine Transport 177
Urine transportation through the ureter
a Peristaltic activity b Pressure gradient

(dilatation)
Figure 12.1 The transport of urine in the ureter is achieved in two
ways: (a) peristaltic activity in which the bolus of urine is pushed
ahead of a contractile wave which almost completely obliterates the
ureteral lumen; (b) pressure gradient (dilated system) in which the
pressure head of bolus is not generated by a contraction of ureteral
smooth muscle fibers but caused by the weight of urine
12.2 Evaluation
Imaging studies are generally used to exclude obstruction at
the level of the ureters or above by detecting dilatation of the
collecting system.
Renal ultrasound, CT scanning, and IVP are the techniques
commonly used to establish the cause of dilatation with a clear
preference for renal ultrasonography to avoid the potential
risks of allergic and toxic complications by contrast media.
When the above radiologic tests demonstrate dilatation
without apparent obstruction or in cases of asymptomatic
dilatation, more specific investigation should be employed in
an attempt to clarify the condition. These include:
Footnote
In presence of dilated ureters a voiding cystourethrog-
raphy (VCUG) should be performed in boys to detect
a vesico-ureteral reflux (VUR) and to evaluate the
posterior urethra for the presence of urethral valves.
• Diuretic renography or diuretic IVP

• Doppler sonography
• Pressure-flow study (Whitaker test)
12.2.1 Diuretic Renography & Diuretic IVP
Diuretic renography or diuretic IVP involves the administra-

tion of a loop diuretic (e.g., 0.5 mg/kg of furosemide) prior to
radionuclide renal scanning or during IVP. The marked
increase in urine flow should, if obstruction is present, slow
the rate of washout of the radioisotope during renal scanning
or further increase the size of the collecting system on IVP.
Diuretic renography typically includes two distinct phase:
• First, radioisotope (TC99m-MAG3 or TC99m-DTPA) is
injected intravenously and renal parenchymal (cortical)
uptake is measured during the first 2–3 min. The relative
contribution of each kidney to overall renal function
12.2 Evaluation 179
counts/min
280000
bladder
160000
right kidney
40000
furosemide left kidney
10 15 20 30 minutes
Figure 12.2 Diuretic renography: diuretic response is evaluated by

visual and quantitative interpretation of the dynamic acquisition of
activity
(called the split renal function) is assessed quantitatively

and is useful as a baseline study. Subsequent studies can be
compared to assess whether kidney function remains sta-
ble or has deteriorated, suggesting true obstruction.
• Second, at peak renal uptake, intravenous furosemide is
administered, and the excretion of isotope from the kidney
is measured, referred to as the washout curve. This phase
indicates the extent of obstruction, if present. In a healthy
kidney, furosemide administration results in a prompt
washout. In a dilated system, if washout occurs rapidly
after diuretic administration (<15 min), the system is not
obstructed. If washout is delayed beyond 20 min, the pat-
tern is consistent with obstructive uropathy (Fig. 12.2).
12.2.2 Doppler Sonography
Doppler sonography may be a useful tool in the differential

diagnosis of hydronephrosis, since it is a noninvasive method
which doesn’t require the administration of contrast medium.
Patency of ureteral flow can be easily assessed detecting
ureteral jets from ureteral meatus (Figure 12.3).
In addition, a study of the intravascular impedance in
renal interlobar arteries can be done.
The effect of pressure increase in the collecting system dur-
ing an obstruction leads to increased resistance to blood flow
and increased levels of interlobar arteries resistivity. The resis-
tive index (RI) calculated through the formula peak systolic
velocity - end-diastolic velocity/peak systolic velocity is a use-
Figure 12.3 Sonographic visualization of ureteral jet depending on

differences in density between the moving and the stationary fluid
ful parameter for quantifying the alterations in renal blood

flow that may occur with obstruction. RI normal value is 0.7.
This method should be applied to both kidneys and may
indicate both a significant increase of RI in the obstructed
kidney or a gradient greater than 0.1 when compared to the
contralateral kidney.
Urodynamic evaluation of upper urinary tract dilatation is
an invasive procedure since it requires a percutaneous access
to pyeloureteral system. For this reason, it should be reserved
for cases where other investigations less invasive such as
diuretic excretory urography or diuretic renography have
produced equivocal results.
12.2.3 Pressure-Flow Study (Whitaker Test)
The pressure-flow study is an antegrade measurement of

pressure in the upper urinary tract to establish whether or not
urinary tract dilatation is caused by obstruction. The test can
12.2 Evaluation 181
Figure 12.4 Percutaneous positioning of nephrostomy tube by

ultrasounds
be used in pediatric age to evaluate a suspected ureteropelvic

(UPJ) or ureterovesical junction (UVJ) obstruction particu-
larly when isotope scan fails to give a definitive answer. This
may be the case in kidneys with severe impairment of func-
tion (differential function of less than 20 %).
The test is minimally invasive, but requires the presence of
an interventional radiologist whose task is to puncture percu-
taneously the pelvis and insert the catheter for the perfusion of
the contrast medium and recording the pressure (Figure 12.4).
The test is performed in two stages: in the first, under gen-
eral anesthesia, a nephrostomy catheter is positioned; in the
second, under mild sedation, the contrast medium, diluted at
50 % with saline, is perfused first at a speed of 10 ml/min and
then at a speed of 20 ml/min. The pressure is recorded simulta-
neously from the upper tract and from the bladder through a
6-Fr catheter positioned into the pelvis through the previously
established nephrostomy tract and a 6-Fr catheter positioned
into the bladder. The differential pressure across the suspected
Footnote
The patient is placed in supine position, catheters are
connected through the lines to external transducers, and
zeroing is performed at pubic symphysis level.
obstruction allows the diagnosis (Figure 12.5). Significant raise

in pressure is indicative of obstruction, whereas free drainage
of contrast at low pressure excludes obstruction.
More precisely
• A raise of pressure greater than 22 cmH2O is indicative of
obstruction.
• A raise of pressure lower than 15 cm H2O excludes an
obstruction.
• A raise of pressure between 15 and 21 cmH2O lies in an
equivocal range.
• If bladder and pelvic pressures increase equally together,
a vesicoureteral reflux should be suspected.
12.2 Evaluation 183
Figure 12.5 Pressure-flow study (Whitaker test): X-ray contrast

medium perfusion of upper urinary tract with differential pressure
measurement (DPP) between renal pelvis and bladder. DPP < 15
cmH2O: unobstructed; DPP between 15 and 22 cmH2O: equivocal;
DPP > 22 cm H2O: obstructed
The test does not actually measure obstruction, but only

records the pressure inside the renal pelvis during a non-
physiological flow rate. Under normal circumstances such
high rates may never be encountered.
There is also the risk that the perfusion end before the
pelvicalyceal system is full. For that reason, fluoroscopy is
needed during pressure measurement to make sure that a
steady state has been reached.
For its complex setup and the risks connected with cathe-
ter placement in the pelvicalyceal system (vascular, colon,
pleural cavity injury), the test has a very limited use.
Suggested Reading
Boddi M, Natucci F, Ciani E (2015) The internist and the renal resis-
tive index: truths and doubts. Intern Emerg Med 10:893–905
Ciftci H, Cece H, Dusak A et al (2010) Study of the ureterovesical jet
flow by means of duplex Doppler ultrasonography in patients
with residual ureteral stone after extracorporeal shock wave lith-
otripsy. Urol Res 38:47–50
Djurhuus JC, Sorensen SS, Jorgensen TM et al (1985) Predicitive
value of pressure flow studies for the functional outcome of
reconstructive surgery for hydronephrosis. Br J Urol 57:6–9
Jandaghi AB, Falahatkar S, Alizadeh A et al (2013) Assessment of
ureterovesical jet dynamics in obstructed ureter by urinary stone
with color Doppler and duplex Doppler examination. Urolithiasis
41:159–163
Keramida G, James JM, Prescott MC, Peters AM (2015) Pitfalls and
limitations of radionuclide renal imaging in adults. Semin Nucl
Med 45:428–439
Whitaker RH (1973) Methods of assessing obstruction in dilated
ureters. Br J Urol 45:15–22
Whitaker RH, Buxton-Thomas MS (1984) A comparison of pressure
flow studies and renography in equivocal upper urinary tract
obstruction. J Urol 131:446
Further Reading
of Urodynamics
The booklet admittently provide only a concise synopsis of

the vast subject of urodynamics.
Recently several books have been published that reader
may consult for a more comprehensive review.
• Peterson AC, Fraser MO (eds) (2016) Pratical urodynam-
ics for the clinicians. Springer
• Rovner ES, Koski ME (eds) (2015) Rapid and pratical
interpretation of urodynamics. Springer
• Griffiths DJ (2014) Urodynamics: the mechanics and
hydrodynamics of the lower urinary tract, 2nd edn. ICS
• Agarwal MM (2014) Manual of urodynamics Jaypee Bros.
Medical Publishers
• Moore KH (2013) Urogynecology: evidence-based clinical
practice. Springer
• Thakar R, Toozs-Hobson P, Dolan L (eds) (2011)
Urodynamic illustrated. RCOG Press
• Chapple CR, MacDiarmid SA, Patel A (2009) Urodynamics
made easy, 3rd edn. Churchill Livingstone Elsevier
• Abrams P (2006) Urodynamics, 3rd edn. Springer
In addition the International Continence Society has
produced a number of standardization reports and
documents concerning the dysfunctions of lower urinary
tract and relative investigations. These documents have be
published widely and are also available on the ICS website
(www.icsoffice.org).

DOI 10.1007/978-3-319-33760-9,
186 Further Reading of Urodynamics
Lastly, Clinical Guidelines for the assessment and manage-

ment of lower urinary tract disorders have been produced by
a number organizations including:
• European Association of Urology (EAU): www.uroweb.org
• American Urological Association (AUA): www.auanet.org
• United Kingdom National Institute for Health and Clinical
Excellence (NICE): www.nice.org.uk
• International Consultation on Incontinence (ICI) available
from: www.icsoffice.org
Appendix A: Urodynamic
Testing Consent Form –
Key Points
Definition
Urodynamic testing (UDT) is an office-based procedure
used to increase the accuracy of diagnosis of symptoms
related to micturition and/or urinary incontinence. The test is
short and minimally invasive. In certain circumstances more
informations can be obtained with the use of fluoroscopy
(real- time X-ray). This is referred as “videourodynamics”.
Preparation
Urodynamic testing does not require particular preparation.
You should arrive to the office with a full bladder so that the
examiner may do an initial “uroflow.” The uroflow is a portion
of the test in which you urinate into a special equipment to
calculate the pattern and force of your stream. If you suffers
of chronic constipation, it is preferable that your bowel is
empty. So take the necessary measures (laxatives, enema) to
do this.
Prior to the procedure the urine will be checked for infec-
tion. If present, the examen will be delayed after an appropri-
ate antibiotics course.
For women of child-bearing age, it is important that we
ensure that you are not pregnant (especially in cases where
we use x-rays). Please inform the examiner if there is any
suspicion that you may be.
187
188 Appendix A: Urodynamic Testing Consent Form – Key Points
Procedure
The procedure typically takes less than an hour. Once your
bladder is empty, you will be asked to lie down on the exami-
nation table. Under sterile conditions, a very thin catheter is
gently inserted through the urethra (the tube through which
you urinate) and into your bladder. Usually a numbing jelly
is used to minimize the discomfort. With the insertion, you
may feel a very slight sting or pinch. Next, a similar catheter
(with a tiny balloon on the end) may be inserted into the
rectum or the vagina and the balloon is filled with a small
amount of water. Once the catheters are secured in place with
tape, the test will begin. The test is usually performed in sit-
ting or supine position.In rare instances it may be performed
in standing position. The catheters are attached to the com-
puter in order to get data about how your bladder and ure-
thra function. The bladder is slowly filled with water until you
are “full” and have a need to urinate. Throughout the filling,
the examiner will be speaking with you so that you may
describe the sensations you are having as your bladder fills.
When you are full, the examiner will ask you to urinate and
empty your bladder into a special container. In certain
instances, the examiner may take x-rays of your bladder dur-
ing the filling and voiding portions of the test. In these cir-
cumstances a different type of fluid (x-ray dye) to fill the
bladder is used instead of water. Dont’ worry about possible
allergies to the dye because the fluid is only in your bladder
and not in your bloodstream. Once you finish voiding, the
catheters are removed and the test is over.
Post Procedure
After the procedure, you might have a little burning in the
urethra until the next time you urinate. In some patients, it
may last a bit longer. If there were any resistance to the
Appendix A: Urodynamic Testing Consent Form – Key Points 189
passage of the catheter, you may even see a tiny blood discol-
oration of urine. Usually there are no restrictions after the
UDT and you may even return to work if you choose.
Possible Complications of the Procedure

All invasive procedures, regardless of complexity or time, can
be associated with unforeseen problems. They may be imme-
diate or even quite delayed in presentation. After UDT the
most common complications include:
• Urinary Tract Infection: Even from a minor and sterile
procedure, it is possible for you to get an infection with
bacteria that typically cause urinary tract infections (UTls).
It may be a simple bladder infection that presents with
symptoms of burning urination, urinary frequency and a
strong urge to urinate. This will usually resolve with a few
days of antibiotics. If the infection enters the bloodstream,
you may feel very ill. This type of infection often presents
with the urinary symptoms and any combination of the
following: fevers, shaking chills, weakness or dizziness,
nausea, and vomiting. You may need a short hospitaliza-
tion for intravenous antibiotics, fluids, and observation.
This scenario is more common in diabetics, patients on
long-term steroids, or patients with any disorder of the
immune system.
If you have high temperatures or any symptoms of
severe illness (fevers, shaking chills, weakness or dizzi-
ness, nausea and vomiting, confusion) let your doctor
know immediately and proceed to the nearest emergency
room.
• Blood in the Urine: In some patients, placing the catheters
within the bladder will cause a very small amount (micro-
scopic) of bleeding; in even fewer patients visible bleed-
ing will be noticed in the urine. In almost all instances, the
urine clears on its own over the next day or so.
190 Appendix A: Urodynamic Testing Consent Form – Key Points
Consent for Treatment

I acknowledge that the physician/health care professional has
explained the proposed procedure to me and has answered
any questions that I have to my satisfaction.
I understand that during the course of the procedure
unforeseen conditions might arise or be revealed that could
require an extension of the procedure or performance of
other operations, procedures or treatments.
I hereby consent to the above procedure. In addition, I
accept all of the risks inherent to that procedure and request
that it be performed.
Index
A AD. See Autonomic dysreflexia

Abdominal examination, 37 (AD)
Abdominal leak point pressure After-anti-incontinence surgery
(ALPP) diagnosis of obstruction, 33
interpretation, 106–107 voiding symptoms in
pitfalls, 107–108 women, 32
quality control, 108 Air-charged catheters, 88–89
technique, 105–106 Air-filled balloon catheters, 145
voiding phase Algorithms
BOO diagnosis in men female stress incontinence, 22
and women, 112–116 increased daytime frequency,
mechanism types, 109–110 12, 13
Pdet@Qmax, 111 male stress incontinence,
pressure events during, 23, 24
109, 110 nocturia, 17, 18
Abdominal pressure (Pabd), 29, nocturnal enuresis, 28, 29
33, 92 painful bladder, 30
ALPP, 105 urgency, 14
ambulatory urodynamics, 172 voiding symptoms
during coughing, 152 in men, 32
EMG activity, 136 in women, 34
leakage of urine, 22 ALPP. SeeAbdominal leak point
measurement, 23, 82 pressure (ALPP)
normal pressure ranges Ambulatory urodynamic
end of filling phase, 108 monitoring (AUM)
end of micturition, 116 bladder and urethral function
Qmax, 111 analyzes, 169
recordings, 93–96, 118, 120 clinical relevance, 173–174
urethral pressure profile, 143 vs. conventional urodynamics,
Abdominal straining, 28, 42, 63, 169
64, 104, 110, 115, equipment, 170, 171
138, 151 ICS definition, 169

DOI 10.1007/978-3-319-33760-9,
192 Index
Ambulatory urodynamic Bladder. See Urinary bladder

monitoring (AUM) Bladder cancer, 29
(cont.) Bladder capacity, 97
indications, 169 anatomic, 11
technique, 170–173 in children, 71
Ambulatory urodynamics, 22, 50, cystometric capacity, 11
51, 81 definition, 10
Anal reflex, 45 estimation, 124
Anal sphincter, 131 functional, 11, 23, 53
electrodes placements, 130, 133 patient’s safe, 104
tone of, 44 reduced, 15, 16, 26
voluntary contraction of, total, 113
44–45 Bladder compliance, 97, 102–104,
Anatomic bladder capacity, 11 117, 124
Anesthesia, 11, 30, 161, 162, 181 Bladder contractility index
Artifacts, 59, 88, 123, 170, 174 (BCI), 111–113
60-Hz, 134 Bladder emptying, 158, 161
minimal motion, 90 incomplete, 10, 33
pelvic floor muscle EMG, lack of inhibition during
133–134 sleep, 26
pressure-flow studies post-void residual urine
filling phase, 117–120 evaluation, 21
ICS recommendations, 117 pressure-flow studies of
voiding phase, 120–121 voiding, 108
uroflowmetry, 66, 68–71 terminal detrusor overactivity,
AUA Symptom Score 98, 99
(AUASS), 101 urge incontinence, 24
AUM. See Ambulatory uroflowmetry, 50
urodynamic monitoring Bladder filling, 2, 3, 29, 81, 135,
(AUM) 143, 146, 169. See also
Automated data analysis, 66 Cystometry
Autonomic dysreflexia (AD) Bladder neck, 143, 144, 147,
emergency in urodynamic 157–160
testing, 161–162 dyssynergia, 31
occurrence, 161 filling phase, 162
prophylaxis, 162 hypertrophy, 148
symptoms, 161, 162 opening, 164, 165
treatment, 162 PTR decreases, 152
Average flow rate, 60 Q-tip test, 38, 40–41
Bladder outlet obstruction (BOO)
definition, 115
B in female, 159
Bedwetting. See Nocturnal ALPP, 113, 115–116
enuresis VUD, 164
Benign prostatic hyperplasia male
(BPH), 34 diagnosis, 112–114
Biochemical tests, 46 uroflowmetry value in, 73
Index 193
voiding symptoms, 49 Coping mechanism, 10

reduced bladder capacity, 16 Cough-induced detrusor
videourodynamics overactivity, 20–21
after incontinence Cough stress test, 20–21, 38
surgery, 22 “Cruising,” 70
in women, 164 Cystometric capacity, 11, 24, 54,
Bladder outlet obstruction index 98, 102, 103
(BOOI), 111, 112 Cystometry, 51
Bladder pain, 29–30 bladder compliance, 102–104
Bladder pressure, 76, 77, 101, 111, bladder sensation
137, 146, 148 capacity, 100
BladderScan, 74, 75 definition, 100
Bladder sensation, 4, 12, 13, 97, oversensitivity, 100–101
100–102, 124 strong desire to void, 99
Body mass index (BMI), 37, 38 detrusor overactivity
BOO. See Bladder outlet cause, 99
obstruction (BOO) definition, 97
BOOI. See Bladder outlet phasic, 98
obstruction index terminal, 98, 99
(BOOI) filling (see Filling cystometry)
Brain filling rate, 96
-bladder control, 14, 24 urethral function, 105
interprets and controls Cytology, 46
sensation, 13
micturition control, 5–6
Bristol nomogram, 66, 68 D
Brown-Wickham method. See Daytime frequency, 10–13
Water profilometry Desire of void
technique compelling, 12, 14
Bulbocavernosus reflex, 45 first, 30, 100
normal, 30
strong, 11, 12, 30, 98–101
C Detrusor contractility, 33,
Catheters 73, 115
air-charged, 88–89 Detrusor contraction, 3, 22, 24,
air-filled balloon, 145 33, 71, 98, 99, 101–103,
fiberoptic, 145 105, 106, 109, 115,
fluid-filled bladder, 88 135–137, 144, 160, 164
microtip, 90 Detrusor dysfunction, 11, 12, 23
rectal, 88, 89 Detrusor function, 21, 97–99
Computed tomography (CT) Detrusor leak point pressure
scanning, 178 (DLPP), 103–104
Conventional urodynamics, Detrusor overactivity (DO), 30,
12, 50 63, 65, 96
equipments, 81–84 AUM, 169, 173, 174
phases, 81 cause, 99
setup, 81, 82 in children, 121, 123
194 Index
Detrusor overactivity (DO) (cont.) E

conventional urodynamics, Ejaculation, 139
22, 173 Electrically adjustable
definition, 97 urodynamic chair,
with dyssynergic urethral 85, 87
sphincter, 121 Electrocardiography, 1
idiopathic, 99 Electroencephalography, 1
neurogenic, 99 Electromyography (EMG)
phasic, 14, 98 AUM, 170
with synergic urethral pelvic floor muscle (see Pelvic
sphincter, 121 floor muscle EMG)
terminal, 14, 98, 99 for pelvic floor muscles
treatment, 28 activity, 51
urge incontinence, 24 Endoscopy, 1
Detrusor pressure (Pdet), 95, Enuresis
102–104, 109, 113, 116, nocturnal (see Nocturnal
117, 125, 137 enuresis)
Detrusor sphincter dyssynergia polysymptomatic, 28
(DSD) External genitalia, examination
abnormal pattern, 136 of, 38
definition, 136
diagnosis, 136
types, 137 F
Detrusor underactivity, 12, 49, Fast bladder, 63–65
112, 113, 115, 165 Females
Detrusor wall thickness (DWT), Liverpool nomogram for,
76, 77 66, 68
Diuretic renography, 178–180 painful bladder, 29
Diuretics, 16 stress urinary incontinence,
DO. See Detrusor overactivity 17, 18, 22
(DO) urethral pressure profile
Doppler sonography, 179–180 resting, 148, 149
DSD. See Detrusor sphincter stress, 151–153
dyssynergia (DSD) uroflowmetry testing
Dysfunctional voiding, 32, 33, flow curve, 65–68
113, 121, 129, 148, 151 setup, 61
abnormal EMG pattern, vaginal examination
135–136 cough test, 38
children with, 28 PFM testing, 42–43
conventional urodynamics, 12 POP-Q, 38–40
fowler syndrome, Q-tip test, 38, 40–41
pelvic floor muscle EMG, videourodynamics
138–139 BOO in, 164
staccato curve, 63, 64 urinary incontinence,
videourodynamics, 165 162–164
and VUDS in BOO, 166 voiding symptoms, 32–34
Index 195
Fiberoptic catheters, 145 definition, 11

Filling cystometry, 24, 30, 33 frequency, 10, 11
detrusor dysfunction, 12 Furosemide, 178
semi-objective test, 102
storage symptoms, 51
urgency assessment, 14 G
USI during, 105 Giggle incontinence, 28
Floppy bladder, 37 Groutz-Blaivas nomogram,
Flow curves 115–116
compressive (BPH) pattern,
61, 64
H
constrictive (urethral
Hesitancy, 30, 121
stricture) pattern,
Hydronephrosis/hydroureter
63, 64
definition, 175
intermittent patterns, 63, 64
differential diagnosis, 179
normal “bell-shaped” curve,
etiology and presentation, 175
61, 63
Hymen, 20, 38, 39
parameters, 65–68
Hypersensitive bladder, 11, 14
staccato (dysfunctional
voiding) curve, 63, 64
supervoider female, 63, 64 I
Flow nomograms ICCS. See International
bristol, 66, 68 Children’s Continence
charts, 65–66 Society (ICCS)
liverpool, 66, 68 ICI Questionnaire Short
siroky, 66, 67 Form on Urinary
Flow rate, 59, 60, 108, 138, Incontinence
176, 183 (ICIQ-UI), 101
Fluid-filled bladder catheters, ICS, 15, 33, 49, 53–55, 59–61, 78,
88, 89 90, 101, 102, 105, 109,
Fourth International 110, 112–114, 117,
Consultation on 144, 169
Incontinence, 74 ICS nomogram, 113–114
Fowler syndrome ICS Standardization
abnormal EMG pattern, Committee, 55
135–136 Incontinence
pelvic floor muscle EMG, giggle, 28
137–138 stress urinary (see Stress
Free flowmetry, 30, 37 urinary incontinence)
male urinary incontinence (see
BOO, 73 Urinary incontinence)
for voiding symptoms, Incontinence Impact
31, 32 Questionnaire (IIQ), 19
post-void residual urine, 12 Incontinence-Quality of Life
Functional bladder capacity Questionnaire
assessment of, 10 (I-QoL), 19
196 Index
Incontinence Severity Index in male (see Males)

(ISI), 19 mental status, 37, 38
Increased daytime frequency, mobility, 37, 38
10–13 physical dexterity, 37, 38
Inferior margin of the pubic Lower urinary tract symptoms
symphysis (IMPS), 163 (LUTS)
International Children’s clinical evaluation, 101
Continence Society pad testing, 54–55
(ICCS), 70 advantage, 57
International Consultation on 1-h pad test, 55–56
Incontinence (ICI), 164 24-h pad test, 56
International Consultation on interpretation, 56–57
Incontinence quantification of urine
Questionnaire lost, 54
(ICIQ), 19 storage symptoms
International Prostate Severity increased daytime
Score (IPSS), 101 frequency, 10–13
Interstitial cells of Cajal (ICC), 176 nocturia, 15–16, 18
Invasive urodynamics nocturnal enuresis in
ambulatory urodynamics children (see Nocturnal
(see Ambulatory enuresis)
urodynamics) painful bladder, 29–30
conventional urodynamics, 50 urgency, 12–14
equipments, 81–84 urinary incontinence (see
phases, 81 Urinary incontinence)
setup, 81, 82 validated questionnaires, 101
Iohexol (Omnipaque), 155 voiding diary
Isovolumetric phase, 109 advantages, 54
application for iPad and
iPhone, 54, 55
L electronic pocket
Leak point pressures recorders, 54
abdominal (see Abdominal ICS recommendation,
leak point pressure) 53, 54
detrusor (see Detrusor leak parameters, 53
point pressure) voiding symptoms
Liverpool nomogram in adult men, 31
for men and women, 66, 68 complaints, 30–31
in pediatric age, 72 in women, 32–34
Lower urinary tract in young men, 31–32
DSD effect on, 136
laboratory evaluation, 46
physical examination M
abdominal palpation, 37 Males
abnormal gait, 37, 38 neurological examination
body mass index, 37, 38 anal tone, 44
in female (see Vaginal categories, 46
examination) dermatomes (S1–S4), 43, 44
Index 197
perineal (“saddle”) N
sensation, 43 Neurological examination, in
sacral reflex activity, 45 male
voluntary squeeze, 44–45 anal tone, 44
PBNO in young, 164–165 categories, 46
rectal examination, 43 dermatomes (S1-S4), 43, 44
resting urethral pressure perineal (“saddle”)
profile, 147–149 sensation, 43
stress incontinence, 22–24 sacral reflex activity, 45
uroflowmetry testing voluntary squeeze, 44–45
with BOO, 73 Neurophysiological EMG,
flow curve, 65–68 129–130
setup, 61 Nocturia
voiding symptoms, 31–32 global polyuria, 15
Maximum anesthetic bladder insomnia, 15, 16
capacity, 11 interruption of sleep, 15
Maximum cystometric capacity, nocturnal polyuria (see
30, 100 Nocturnal polyuria)
Maximum flow rate, 59, 77 reduced bladder capacity,
Maximum pressure, 109, 15, 16
143, 149 simplified algorithm, 17, 18
Maximum urethral closure terminology, 16
pressure (MUCP), Nocturia index (Ni), 16
27, 143 Nocturnal bladder capacity
Maximum voided volume (NBC), 16
(MVV), 11, 16 Nocturnal bladder capacity index
Medial motor areas, 7 (NBCi), 16
Men. See Males Nocturnal enuresis
Microtip catheters, 90 algorithm, 28, 29
Micturition bowel control, 26
brain control of, 5–6 diagnosis of, 26–27
cycle disorders, 27
lower urinary tract giggle incontinence, 28
symptoms (see Lower noninvasive uroflowmetry,
urinary tract 28
symptoms) terminology, 26
and peripheral nervous urodynamics testing, 28
pathways, 3–5 Nocturnal polyuria
storage and emptying causes, 15
process, 1–2 definition, 15
uretheral sphincter, 3 occurrence
Minimum voided volume, 70 sleep apnea, 16
Mixed urinary incontinence solute diuresis, 15
(MUI), 25–26 water diuresis, 15
Multichannel urodynamic Nocturnal polyuria index
equipment, 83 (NPi), 16
MVV. See Maximum voided Nocturnal urinary volume
volume (MVV) (NUV), 16
198 Index
Noninvasive urodynamics, 50 P
bladder/DWT technique, Pabd. See Abdominal pressure
76, 77 (Pabd)
new techniques, 75–76 Pad testing, 54–55
penile cuff compression advantage, 57
technique 1-h pad test, 55–56
interpretation, 77, 78 24-h pad test, 56
principle of, 76 interpretation, 56–57
setup, 77, 78 quantification of urine lost, 54
post-void residual urine Painful bladder, 29–30
BladderScan, 74, 75 Palpation, 37
by catheterization, 74 Pdet. See Detrusor pressure
definition, 74 (Pdet)
evaluation, 74 Pdet@Qmax, 111
normal values of, 74–75 Pelvic floor muscle EMG
real-time abdominal abnormal EMG patterns, 135
ultrasound, 74 activity during micturition
uroflowmetry cycle, 135
advantages, 73–74 AUA/SUFU guidelines, 129
artifacts, 66, 68–71 common artifacts, 117–118
definition, 59 DSD
disadvantages, 73–74 definition, 136
flow curve reading, diagnosis, 136
61–66 types, 136–137
ICS terminology, 59–60 dysfunctional voiding,
measuring techniques, 138–140
60–61 electrodes
in pediatric age, 70–72 needle, 130, 132
predictive value in men positioning of, 132
with LUTS, 73 surface, 130–133
wire, 133
Fowler syndrome, 137–138
O Parkinson’s disease, sphincter
Obstructive uropathy, 179 bradykinesia in, 140
1-h pad test, 55–57 qualitative, 129–130
Opening pressure, 109 quantitative, 129
Opening time, 109 uses, 129
Overactive bladder (OAB) Pelvic floor muscle (PFM)
children with, 28 testing, 42–43
with leakage (wet), 25 Pelvic organ prolapse
polysymptomatic quantification system
enuresis, 28 (POP-Q) exam, 38–40
prevalence of, 25 Pelvic pain, 29
reduced bladder capacity, 16 Pelvic prolapse staging, 38, 40
urgency, 12–14 Penile cuff compression
without leakage (dry), 25 technique
Index 199
interpretation, 77, 78 setup, 123

principle of, 76 with spinal dysraphism,
setup, 77, 78 121
Periaqueductal gray (PAG) voiding phase, 125
region, 4–6, 13 upper urinary tract
Physical examination minimally invasive, 181
abdominal palpation, 37, 38 nephrostomy tube
abnormal gait, 37, 38 positioning, 181
body mass index, 37, 38 in pediatric, 181
female x-ray contrast medium
stress test for urinary perfusion, 181
incontinence, 38 voiding process, 51
vaginal examination (see Pressure recording, 109, 145
Vaginal examination) Pressure transducers, 170
in male Pressure transmission ration
neurological examination (PTR), 144
(see Neurological Profilmetry. See Urethral
examination, in male) pressure profile (UPP)
rectal examination, 43 Prostatic surgery, 73, 148
mental status, 37, 38 PVR. See Post-void residual
mobility, 37, 38 urine (PVR)
physical dexterity, 37, 38
Pontine micturition center
(PMC), 5 Q
Post-void residual urine (PVR) Q-tip test, 38, 40–41
BladderScan, 74, 75 Questionnaire for Urinary
by catheterization, 74 Incontinence Diagnosis
definition, 74 (QUID), 19
evaluation, 74
normal values of, 74–75
real-time abdominal R
ultrasound, 74 Radioisotope, 178
Predicted number of nightly Recording unit, 170
voids (PNV), 16 Rectal catheters, 88, 89
Pressure-flow studies, 51, 174 Rectal contractions, 120
artifacts Rectal examination, 43
filling phase, 117–120 Rectal pressure, 108, 118
ICS recommendations, 117 Renal ultrasound, 178
voiding phase, 120–121 Resistive index (RI), 179
in pediatric age Rotating disk transducer, 60
bladder physiology
assessment, 122
dysfunctional voiding, 122 S
filling phase, 124–125 Schaefer nomogram, 113, 114
posterior urethral valves, Siroky nomogram, 66, 67
121 Smooth muscle sphincter, 3
200 Index
Somatic nervous system, 3 Triple-lumen catheter, 146

Sphincter bradykinesia in 24-h pad test, 56, 57
Parkinson’s disease,
136, 140
Storage symptoms U
increased daytime frequency, Ultrasonography, 28, 178
10–13 Ultrasound, 23, 50, 74, 77, 180
nocturia, 15–16, 18 UPP. See Urethral pressure
nocturnal enuresis in children profile (UPP)
(see Nocturnal Upper urinary tract
enuresis) DSD effect on, 136
painful bladder, 29–30 evaluation
urgency, 12–14 diuretic renography/
urinary incontinence (see diuretic IVP, 178
Urinary incontinence) Doppler sonograpy,
Straining, 154, 155, 172 179–180
abdominal, 28, 42, 63, 64, 104, pressure-flow study,
110, 117, 138, 151 180–183
bladder neck, 158 hydronephrosis/hydroureter,
to void, 68, 69 175
Stress urinary incontinence urine transportation through
definition, 17 ureter, 177
in female, 17, 18 Ureteral catheter, 23, 98, 123
involuntary loss of urine, 17 Ureteral electrical
in male, 22–24 conductance, 170
uncomplicated vs. Ureteral peristalsis, 176
complicated Ureteropelvic (UPJ), 181
ACOG guidelines, 19 Ureterovesical junction
cough stress test, 20–21 (UVJ), 181
history, 19–20 Urethral closure pressure
physical examination, 20 profile, 143
post-void residual urine Urethral function, 21, 50, 97, 105,
measurement, 21 108, 169
urethral mobility Urethral hypermobility, 17, 21,
assessment, 21 38, 106, 107, 164
urinalysis, 20 Urethral pressure profile (UPP)
videourodynamics, 22 advantages, 145
Sublingual nifedipine, 161 clinical role at rest, 151
curve
morphology, 148–150
T resting phases, 146–148
Total vaginal length, 39 disadvantages, 145
Transducers female stress, 150–152
microtip, 87 ICS terminology, 143–144
sterility of, 93 measurement method,
weight, 60 144–145
wireless, 61 normal values, 149–150
Index 201
performance, 143 Urinary tract infections (UTIs),

water profilometry technique, 20, 27–29, 46, 91
145–146 Urinary tract infection testing, 46
Urethral resistance, 2, 104, 107 Urine flow
Urethral syndrome. See gravitational of, 2
Dysfunctional voiding onset of, 109
Urgency rate, 108, 176
algorithm, 14 stops, 2, 31
compelling desire to void, 12 Urodynamics (UDS), 1
filling cystometry, 14 advantages, 49
OAB, 12 ambulatory (see Ambulatory
sensation of, 12–14 urodynamics)
urge vs., 101–102 conventional (see
Urge urinary incontinence Conventional
in aging, 23–24 urodynamics)
filling cystometry, 24 cystometry (see Cystometry)
in male, 25 EMG, 51
management, 25 equipment types
subtypes, 24–25 catheters, 87–91
surgical treatment, 25 electrically adjustable
symptom-based urodynamic chair, 85,
diagnosis, 24 87
urine loss, 24 wireless urodynamic
Urinalysis, 19, 20, 29 equipment, 85, 86
Urinary bladder flow measurements (see
afferent and efferent nervous Uroflowmetry)
pathways of, 3–5 and function investigated, 50
function, 1 guidelines, 49
micturition cycle (see manufacturers list, 84, 85
Micturition) noninvasive evaluation (see
Urinary incontinence Noninvasive
female, 162–164 urodynamics)
mixed incontinence, 25–26 parameters, acronyms of,
phasic detrusor 50, 51
overactivity, 98 patient’s preparation
questionnaires, 19 baseline pressure
stress incontinence checking, 93–94
definition, 17 catheter insertion, 92
in female, 17, 18 EMG electrode
involuntary loss of placement, 91
urine, 17 initial resting pressures,
in male, 22–24 94, 95
uncomplicated vs. microtip and air-charged
complicated, 19–23 catheter position, 95
urge incontinence, 23–25 PVR measurement, 92
Urinary leakage, 103–105, 164 quality of signal check,
Urinary retention, fear of, 10 95–96
202 Index
Urodynamics (UDS) (cont.) V

urethra sterilization, 91–92 Vaginal examination
3-way taps position, 92–93 cough test, 38
pressure/flow study (see PFM testing, 42–43
Pressure-flow studies) POP-Q, 38–40
urethral function (see Q-tip test, 38, 40–41
Urethral pressure Vaginal palpation, 41
profile (UPP)) Videocystouretrography
urodynamic stress (VCUG), 157, 158
incontinence, 105 Videourodynamics (VUDS), 51
videourodynamics, 51 BOO in women, 164
Urodynamic stress incontinence, female urinary incontinence,
105, 106 160, 162–164
Uroflowmeter, 170, 172 fluoroscopy imaging
Uroflowmetry, 9, 50–51 disadvantages, 166
advantages, 73–74 lower urinary tract,
artifacts, 66, 68–71 155–156
definition, 59 ICS-RS guidelines, 166
disadvantages, 73–74 in myelomeningocele, 160
flow curve reading in neurogenic bladder, 159
compressive (BPH) filling phase, 159–160
pattern, 61, 64 voiding phase, 160–162
constrictive (urethral patients with SD and
stricture) pattern, 63, 64 SCI, 158
intermittent patterns, 63, 64 PBNO in young male, 165
normal “bell-shaped” procedure, 155–158
curve, 61, 63 role in nonneurogenic
numerical parameters, LUTD, 159
65–68 X-ray imaging, 156
staccato (dysfunctional Voided volume, 53, 59–61, 65, 66,
voiding) curve, 63, 64 71–72
supervoider female, 63, 64 low, 27
ICS terminology, 59–60 maximum, 16
measuring techniques minimum, 70, 125
equipment setup, 60–62 Voiding
rotating disk tranducer, 60 desire (see Desire of void)
weight transducer, 60 dysfunction, 11
in pediatric age, 70–72 involuntary reflex at
predictive value in men with childhood, 5
LUTS, 73 stimulus of, 1
Urogenital Distress Inventory by straining, 68, 69
(UDI), 19 voluntary onset of, 2, 3
Urogenital Distress Inventory Voiding cystograpy, 33
Short Form Voiding cystourethrography
(UDI-6), 101 (VCUG), 158, 178
UTIs. See Urinary tract Voiding diary, 10, 14
infections (UTIs) advantages, 54
Index 203
application for iPad and Weight transducer

iPhone, 54, 55 flowmeter, 60
electronic pocket recorders, 54 Whitaker test. See Pressure-flow
ICS recommendation, 53, 54 studies
parameters, 53 Wireless Bluetooth AUM
Voiding efficiency index unit, 165
(VEI), 113 Wireless transducers, 61
Voiding symptoms Wireless urodynamic equipment,
in adult men, 31 85, 86
complaints, 30–31 Women. See Females
in women, 32–34
in young men, 31–32
Voluntary striated sphincter, 3
X
VUDS. See Videourodynamics
X-ray, 155, 159, 183
(VUDS)
W
Water profilometry technique, Z
145–146 Zero pressure, 91, 93, 118, 170

Urodynamics (Aquick Pocket Guide)

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Urodynamics (Aquick Pocket Guide)

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Giancarlo Vignoli

ISBN 978-3-319-33758-6 ISBN 978-3-319-33760-9 (eBook)

Library of Congress Control Number: 2016953671

© Springer International Publishing Switzerland 2017

Printed on acid-free paper

This Springer imprint is published by Springer Nature

Since its introduction 30 years ago, urodynamics has produced

lot of academics but little practice. Paradoxically, when one

Bologna, Italy Giancarlo Vignoli

Special thanks to my wife Claudia and my friend Mr. Vanni

1 The Framework of Basic Science. . . . . . . . . . . . . . . . 1

2 Key Symptoms Analysis and Diagnostic

3 Physical Examination and Laboratory Tests . . . . . . 37

4 Urodynamic Testing: When and Which. . . . . . . . . . . 49

5 Voiding Diary and Pad Testing . . . . . . . . . . . . . . . . . 53

6.6.1 Bladder/Detrusor Wall

8 Electromyography of Pelvic Floor Muscles . . . . . . . 129

8.2 DSD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

9 Urethral Profilometry . . . . . . . . . . . . . . . . . . . . . . . . . 143

10 Videourodynamics (VUDS) . . . . . . . . . . . . . . . . . . . . 155

11 Ambulatory Urodynamics . . . . . . . . . . . . . . . . . . . . . 169

12 Urodynamics of the Upper Urinary Tract . . . . . . . . 175

Further Reading of Urodynamics . . . . . . . . . . . . . . . . . . 185

Appendix A: Urodynamic Testing Consent

ACC Anterior cingulate cortex

NBCi Nocturnal bladder capacity index

1.1 What Is Urodynamics?

Urodynamics is the study of the function of the lower urinary

1.2 The Micturition Cycle

Figure 1.1 The micturition cycle. As the bladder fills, relaxation of

Typically the bladder empties seven times a day and, usu-

One third of bladder filling takes place without the indi-

Figure 1.2 Afferent and efferent nervous pathways of the bladder.

1.3 The Brain

Figure 1.3 Brain control of micturition. Information on the intra-

Medial motor areas (SMA, M1) may govern directly the

There are several standardized validated questionnaire to aid

2.1 Storage Symptoms

2.2 Increased Daytime Frequency

Box 2.1: Definition of Bladder Capacity

Bladder capacity may be defined in three contexts:

Functional bladder capacity is defined as the volume

If functional bladder capacity is normal, increased fre-

Free flowmetry with assessment of post-void residual urine

In literature the terms urge and urgency are often

Although urgency is the distinctive feature of overactive

Increased daytime frequency

Urinanalysis & culture Voiding diary

Det. dysfunction Bladder outlet

filling cystometry multichannel UDS

Figure 2.1 Simplified algorithm of increased daytime frequency

• The processes by which the sensation is transmitted to the

stronger activity at high volumes, suggesting a sudden

Voiding diary ? Pain scales ?

Figure 2.2 Simplified algorithm of urgency

Nocturnal polyuria can also occur in consequence of sleep

Box 2.3: Terminology of Nocturia Based on Voiding Diary

NUV (nocturnal urinary volume) = the amount of

For nocturia simplified algorithm, see Fig. 2.3.

2.5 Urinary Incontinence

2.5.1 Stress Incontinence

Stress incontinence is the complaint of involuntary loss of

1. Defect in the urethral support for a weakening of the mus-