Practical Urodynamics for the Clinician

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These simple parameter tests while useful, easy to perform and reliable cannot answer these more involved questions. The next level of urodynamic testing encompasses the more advanced measurements which track two or more parameters. They are essentially small scale simulations. The cystometrogram CMG with or without electromyography, rectal or vaginal pressure monitoring, and urethral pressure tracking are examples. The CMG, often the unappreciated workhorse urodynamic test tracks two parameters—infused bladder volume and intravesical storage pressure.

It is however very poor in documenting the presence or absence of overactivity in the non-neurogenic patient. It is a paradox that the act of testing may confound the test. Superficially it may seem that the CMG would be ideal for this purpose since it seems to simulate the situation many patients with bladder overactivity OAB encounter— an unexpected sense of urgency during routine bladder filling.

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Yet, in practice the act of testing often yields a high false negative result, making it practically useless as a screening test for this purpose [ 4 ]. The solution to this paradox lies in the understanding that the act of testing does not in fact recreate a true simulation of the clinical circumstance. The typical overactive adult patient reports being caught off guard with a sudden feeling of urgency or even urge incontinence. During testing the patient is awake, catheterized and is now consciously focused on the bladder, its sensations and the pelvis in general.

The act of testing is creating an artificial situation. Rather than the more accurate depiction with a distracted patient, the test creates a misleading situation where the patient is completely focused on the bladder. During the test, this focus helps prevent the occurrence of the over activity. But this level of bladder focus is not possible practically for most patients who are trying to carry on with their lives. Two common situations include the man who is having difficulty voiding and the woman with intermittent incontinence which may be related to stress.

The best known of these are the pressure flow and stress incontinence tests which are done commonly with fluoroscopy. These tests track the infused bladder volume, intravesical storage and voiding pressures, coordination of the bladder neck and sphincter as well as urinary flow and leakage.


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The key factor is that at an appropriate point when the bladder is filled to the level that approximates the usual clinical situation, the patient is asked to volitionally void or bear down and try to recreate the leakage or obstruction. We can visualize and note at what volume and how much pressure measured in cm H 2 O it takes to induce leakage or how much pressure it takes to drive urine across the obstructive prostatic hypertrophy.

The study therefore not only should capture the event, but it also allows us to quantify the forces involved thereby revealing objective measurements which can be used to compare treatment results and efficacy. The Urodynamic Laboratory The distinction between urodynamic tests is not merely an academic or intellectual one. They become important when one considers setting up an urodynamic laboratory.

For simple measurements one can easily set up the lab so the tests can be done by the support staff. The instructions and set ups are simple and require no direct provider supervision. It becomes trickier with the more complex studies. Basically these studies can be one of two ways. They can be done by the urologist with assistance from his support staff or in some cases they can be done completely by the assistants themselves and read by the urologist after testing is completed.

There are nurses, physician assistants and medical assistants who are quite skillful, well trained and fully capable of performing even the most complicated studies. If the urologist is going to be present at each test then the issues about clinical context discussed earlier is still important. The urologist is physically present and can talk with the patient directly and can be assured that the desired simulation is recreated.

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Simply having the team undergo a training course is not sufficient. After 20 years of teaching courses to urologists who are trying to incorporate urodynamics into their daily clinical practice, the failure to recognize the need to establish a consistent common understanding among all of the team members including the urologist, is the primary cause of most unsuccessful efforts to implement urodynamics into an existing practice.

Lacking a clear grasp of the aim of the study and what exactly the urologist is seeking to discover the team can become unsure and may not provide the needed information or do studies which are unnecessary out of fear of overlooking something. The urologist can become frustrated at the output being received and loses confidence in the team and the utility of the tests.

The urologist who will be interpreting the results and the team performing the test must have a shared understanding of how the tests are done and how the results are recorded and presented. Ideally the team and the urologist should do a series of tests together over 6—12 months so that they develop the same understanding of how the tests are conducted, the terminology and have an established protocol of how the data are stored and displayed. The ICS best urodynamic practices document is a helpful aid in establishing standardized practices for urologist and testing team [ 6 ].

However, these highly competent in small numbers and the standards are still evolving. A urodynamics department should operate within the maintaining expertise, curricula and assessment tools, and context of a multidisciplinary team MDT , which holds certification. With different requirements for service provision regular meetings to discuss patient management relating in units, it is expected that service providers will benchmark to urodynamic findings.

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In time, and with. A urodynamics department should operate under the adequate training, it is expected that all urodynamic units clear direction of a senior urodynamicist. This will usually across the UK would conform to these minimum standards for be either a urologist with a special interest in LUTS or a urodynamics provision.


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In order to provide a standardized framework, it was. A department should define the scope of its expertise see decided that the statement should conform to the UK PMETB modules below and not undertake to provide a urody- Postgraduate Medical Education and Training Board format- namic service outside of that scope. Modular training also lends itself.

General Recommendations. Departments should undertake audit. Presenting and discussing cases at MDT studies at that level and is presented in a tabular format, the meetings is vital for training. Each module addresses four listed and referenced in our document see website: steps—the tables being laid out in columns to reflect this www.

Practical Urodynamics for the Clinician (Buch)

Training and certification. The required knowledge base in video urodynamics requires competence in the basic. Setting up the equipment modules A1 and A2 , ionizing radiation protection. Preparation of the patient and conducting the test procedures, and contrast medium usage and allergies as well.

Arrangements for training and supervision. Module A1 female and A2 male. Urologists with Synchronous fluoroscopy adds to the test and the ability to a special interest in urodynamics would usually complete recognize and grade vesico-ureteric reflux VUR , detrusor basic training and have experience in both A1 and A2; sphincter dys-synergia DSD , bladder neck descent, and urogynecologists would usually seek basic training and other radiological abnormalities is important.

Knowledge of competence in module A1.

The Urodynamic Laboratory

All clinicians including nurse proper application of the test to clinical problems is practitioners, continence advisors, physiotherapists, basic paramount. Clinical skills and competencies need to be scientists, and others could be trained and certified in these assessed following training under an identified preceptor modules, depending on the requirements of the unit. Further with a minimum of 40 cases and regular attendance at video- modules in advanced practice will be completed after basic urodynamic clinics and multidisciplinary team meeting training Tables I and II.

MDM relevant to the clinical areas covered. Certification with attendance at an accredited course is Urodynamics in neuropathic patients Module C.


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Course attendance alone is not enough to Urological management of patients with neurological confer competence so additional training support will be disability requires specialized care and should only be done provided by regular attendance at urodynamic clinics and in experienced units. Neurological conditions affecting the competency assessment both informally at these clinics and bladder include traumatic spinal cord injuries as well as formally with directly observed procedures DOPS and case- congenital and acquired neurological diseases such as spina based discussions CBD ; these will be curriculum based.

For further details on the methodology for each of these measures please see the following websites: Intercollegiate Surgical Curriculum Project www. Neurourology and Urodynamics DOI Relevant neurological conditions such as spinal shock, both in the genesis of incontinence and their role in autonomic dysreflexia, posttraumatic syringomyelia, and influencing renal function. These include spasticity control and urodynamics appreciated Table III. The role of ambulatory of 50 neuropathic patients and dedicated video-urodynamic tests in answering a specific urodynamic question should be sessions; this has to be done under an identified preceptor and understood; and counseling the patient in accurate recording of with a minimum of 40 video tests done on the neuropathic symptoms and a timed filling and voiding diary and ensuring patients.

The urodynamicist should have attended an the patient understands what is required of them and trouble approved spinal injuries course and discuss such patients at shooting with catheter expulsions makes for a meaningful regular MDM. The investigator should be able to analyze the tracings, correlate them to symptoms, report on them, and formulate a management plan Table IV. Ambulatory urodynamics Module D.

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Ambulatory uro- Training in the ambulatory module is done only when the dynamics is a highly specialized small volume test and should investigator is proficient in modules A and B and requires Neurourology and Urodynamics DOI MDT, multidisciplinary team. Children have terminology of lower urinary tract symptoms and grades of different needs and sensitivities, one should be comfortable VUR is important.

As with other invasive procedures and more relating to them, be adaptable and inspire confidence; some of so with children , the indications for antibiotic prophylaxis, them may need sedation and written parental consent is dosages, and usage must be clear. Synchronous fluoroscopic necessary. This same clinician should be protection including allergies to contrast is necessary Table V. Since urodynamics formally through DOPS and CBDS, this is done under a named is intrinsically an interactive investigation it is unacceptable preceptor and the minimum requirement is 20 pediatric that anyone undertaking the test should not be fully versed in urodynamic sessions.

The practitioners should be involved in these basic principles. The practitioner should therefore be the management of pediatric patients and participate in MDT able to construct the urodynamic question, ensure that the where such patients are presented and discussed.