|Year : 2000 | Volume
| Issue : 2 | Page : 183-189
Simple clinical (non-electronic) urodynamic tests for understanding and assessment of voiding cycle symptoms (altered lower urinary tract function) in common clinical conditions
Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Urodynamics is the study of voiding cycle (storage and emptying cycle) of the lower urinary tract. Voiding cycle can be studied by clinical (non-electronic) and laboratory (electronic) urodynamic tests. Various clinical (nonelectronic) urodynamic tests are briefly described. Relevant literature is reviewed to suggest that clinical (nonelectronic) urodynamic tests can help in the management of most patients with voiding cycle symptoms (altered lower urinary tract function).
Keywords: Urodynamics; Clinical Urodynamics; Lower Urinary Tract Function; Lower Urinary Tract Dysfunction; Voiding Cycle Symptoms.
|How to cite this article:|
Kumar S. Simple clinical (non-electronic) urodynamic tests for understanding and assessment of voiding cycle symptoms (altered lower urinary tract function) in common clinical conditions. Indian J Urol 2000;16:183-9
|How to cite this URL:|
Kumar S. Simple clinical (non-electronic) urodynamic tests for understanding and assessment of voiding cycle symptoms (altered lower urinary tract function) in common clinical conditions. Indian J Urol [serial online] 2000 [cited 2020 Mar 28];16:183-9. Available from: http://www.indianjurol.com/text.asp?2000/16/2/183/22233
| Introduction|| |
Everything should be made
as simple as possible,
but not simpler.
(Reader's Digest, Oct. 1977)
Urinary tract is a system of narrow tubes designed to transport urine from kidneys to the exterior. For human convenience, a reservoir (the bladder) is incorporated in the lower urinary tract for temporary storage of urine and its subsequent expulsion at appropriate time and place. Disorders of storage and emptying function (voiding cycle) of the lower urinary tract need understanding and assessment of altered function for their proper management.
The word urodynamics has two connotations according to Turner-Warwick. 
- It implies, especially in Europe, "the objective evaluation of urinary tract function and dysfunction by whatever test is appropriate from the simplest to the most sophisticated".
- It means, particularly in North America, "the technical electronic study of pressure, uroflow and muscle action potentials conducted in a laboratory".
Etymologically, the first connotation is more acceptable. Urodynamics is the hydrodynamics of the urinary tract.  Hydrodynamics is the branch of physics that deals with the flow of liquids.  Thus urodynamics is the study of the flow of urine in the urinary tract by any method. The flow of urine includes storage and emptying cycle (voiding cycle) in the lower urinary tract.
Urodynamic methods could be classified into following two groups following the suggestion of Hinman. ,
- Clinical urodynamics (Non-electronic urodynamics)
- Laboratory urodynamics (Electronic urodynamics)
Electronic urodynamics is performed in a urodynamics laboratory using a commercially available urodynamics machine. Various urodynamic parameters and methods of their assessment by clinical (non-electronic) and laboratory (electronic) urodynamics are summarised in [Table 1].
| Evolutionary Phases of Urodynamics|| |
It is instructive to summarise the five phases of urodynamics as described by Hinman. 
1. The Phase of Hydrodynamics.
In this phase the basic rules of fluid mechanics were discovered.
2. The Phase of Urodynamics.
In this phase various measuring instruments were developed.
3. The Phase of Commercialization.
Urodynamics equipment was mass produced and marketed with the promise of precise diagnosis of urinary tract dysfunction.
4. The Phase of Centralization.
It became obvious that urodynamics equipment did not provide automatic diagnosis. Clinicians returned to simpler methods of assessment and only patients with difficult problems are referred to a centralized urodynamics laboratory.
5. The Phase of Neurourology.
The role of nervous system is being defined and there is an increasing appreciation of emotions as a source of urinary problems.
| Basic Urodynamic Questions|| |
According to Hinman  basic urodynamic questions include the following:
- How much the bladder holds at normal pressure (Resting bladder pressure and capacity).
- What pressure it generates to empty (Maximum bladder pressure).
- Whether the urethra functions reciprocally (Urethral pressure).
- How free the flow is (Urine flow rate and velocity).
- Whether voiding is complete (Residual urine volume).
- Whether the act is controlled and coordinated (My oneural co-ordination).
| Dimensions of Urinary Flow Studies|| |
The dimensions and types of urinary flow studies are given in [Table 2]. The most commonly performed urinary flow study has the following features:
- It measures urinary flow.
- It is performed by a doctor.
- It considers a single voiding.
- It is done in a hospital.
- Instrument used for measurement is a stopwatch or a uroflowmeter.
| The Role of Clinical (Non-Electronic) Urodynamics|| |
Steers and others  mention in "Adult and Pediatric Urology" that "In most clinical settings, it is usually practical and more cost-effective to screen patients by performing stopwatch uroflowmetry, ultrasonographic measurement of post-void residual volume and eyeball cystometry using a catheter tip syringe".  They further state that "these simple tests will help the clinician understand the patient's symptoms in most cases." More sophisticated electronic urodynamics are required when simple diagnostic procedures are inconclusive and when history and physical examination suggest neurologic disease. 
The role of clinical and laboratory urodynamics can be represented in the form of a urodynamic pyramid [Figure 1]. All patients with lower urinary tract dysfunction need some kind of clinical (non-electronic) urodynamics for the understanding of their problems. Some of these patients would later need some kind of laboratory (electronic) urodynamics in a laboratory for further assessment of their problems.
| Clinical (Non-Electronic) Urodynamic Tests|| |
Various clinical (non-electronic) urodynamic tests [Table 1] are briefly described.
1. Urodynamically or Functionally Classified Voiding Cycle Symptoms (VCS)
A urodynamic or functional classification of voiding cycle symptoms [Table 3] identifies storage symptoms and emptying symptoms. Storage symptoms are caused by either bladder overactivity or urethral incompetence.  Emptying symptoms are caused by either urethral obstruction or bladder underactivity. [Table 3] also gives a method of recording voiding cycle symptoms.
2. Time Volume Record (TVR)
In Time Volume Record the patient records time and volume of urine voided on a chart [Table 4] for 48 hours. This record is usually called frequency-volume chart,  urolog  or urinary or voiding diary.  The name Time Volume Record facilitates its explanation to patients. It measures functional bladder capacity. Turner-Warwick calls it a natural volumetric cystometrogram. 
Time Volume Record provides information about sleeping time frequency, waking time frequency, largest single voided volume, mean voided volume, diurnal distribution and total voided volume. Female patients may also be asked to record strength of urgency and amount of leakage on the Time Volume Record. 
3. Post-Void Residual (PVR) Urine Volume
The measurement of post-void residual urine volume is commonly used and is recommended by International Consultation on Benign Prostatic Hyperplasia.  Post-void residual urine volume can be measured by ultrasonography, during intravenous urography and during cystoscopy.
4. Bladder Capacity (BC)
Bladder capacity can be measured by ultrasonography, during intravenous urography and during cystoscopy. Bladder capacity can also be easily measured in patients having indwelling urinary catheters. Bladder capacity can be small, normal or large. Information about bladder capacity helps in better understanding of voiding cycle symptoms.
5. Bladder Capacity in Retention (BCR)
Simple measurement of the volume of retained urine during catheterisation for retention of urine indicates Bladder Capacity in Retention (BCR). It helps in the identification of chronic retention of urine.
6. Stopwatch Uroflowmetry
Stopwatch uroflowmetry is recommended for clinical urodynamic evaluation , In 1995, US medicare programme paid $542,600,000 for simple uroflowmetry using a stopwatch and $17,031,000 for complex uroflowmetry using electronic equipment.  Multiple freeflow studies are needed to provide reliable data.  Uroflowmetry is stated to be of limited use in the evaluation for benign prostatic hyperplasia. 
7. Simple Cystometry
Simple cystometry can be performed either by using a simple water manometer  or by using a 50 or 60 ml catheter-tip syringe without piston (Eyeball Urodynamics). ,,
Eyeball urodynamics is the simplest form of cystometry. It gives valuable information about bladder filling phase. Apparent bladder contractions can be interpreted using a simple scheme [Figure 2]. It has been commonly used in female patients.
8. Neurourological Tests
These include testing of perineal sensation, rectal tone and bulbocavernosus reflex. They provide information about sacral reflexes.
9. Voiding Cystourethrography
Voiding cystourethrography with fluoroscopic monitoring provides an accurate method of identifying the site of bladder outlet obstruction.
Turner-Warwick developed intravenous urodynamogram, intravenous cystodynamogram and ultrasound cystodynamogram.  A cystodynamogram combines the measurement of bladder capacity, urinary flow and postvoid residual [Table 5]. It can be performed during cystoscopy also.
| Suggested Clinical Urodynamic Workup for Elderly Men With Voiding Cycle Symptoms (VCS)|| |
I. Patients presenting with urinary retention.
- Bladder Capacity in Retention (BCR).
- Bladder Capacity (Periodic measurement in cases of chronic urinary retention).
- Simple Cystometry.
II. Patients not presenting with urinary retention.
- Urodynamically Classified Voiding Cycle Symptoms (VCS).
- Time Volume Record (TVR).
- Ultrasonographic Cystodynamogram.
| Concluding Suggestions|| |
According to Hinman,  "Most voiding problems in urologic practice can be solved by intelligent application of simple urodynamic tests. The more complex electronic procedures should be performed at well-equipped centres for complicated cases." This statement is highly relevant to developing countries like India where expensive urodynamic equipment may not be available at many places.
It is suggested that simple clinical urodynamic tests should be universally used in the assessment of voiding cycle symptoms. If urodynamic machine is not available, these tests will help in managing most of the common problems. If urodynamic machine is available, these tests will help in formulating proper urodynamic questions to be answered by electronic urodynamics.
The absence of wind does not mean
the absence of air. Similarly, the absence
of urodynamic machine does not mean
the absence of urodynamic tests.
The specialist who has invested in
expensive diagnostic equipment is
motivated to use that equipment even when
the indications are marginal.
F J. Ingelfinger 
| Limitations of Laboratory (Electronic) Urodynamics and Emerging Trends|| |
Factors reducing reliability of urodynamic data include short duration of tests, degree of immobility during the investigations and laboratory setting.  These limitations have led to the emergence of trends like home uroflowmetry  and ambulatory urodynamics. 
| References|| |
|1.||Turner-Warwick R. Foreword. In: Urodynamics - Principles, Practice and Application. Eds: Mundy AR, Stephenson TP, Wein AJ.Edinburgh: Churchill Livingstone, 1984: v-vi. |
|2.||Stedman's Medical Dictionary. 23rd edition. New Delhi: S. Chand,1976. |
|3.||Hinman F Jr. Urodynamic testing: Alternatives to electronics. Journal of Urology 1979; 121: 643-645. [PUBMED] |
|4.||Hinman F Jr. Office evaluation of urodynamic problems. Urologic Clinics of North America 1979; 6 (1): 149-154. |
|5.||Hinman F Jr. Foreword. In: Urodynamics I. Ed: Boone. TB. Urologic Clinics of North America 1996; 23 (2): xi-xii. |
|6.||Steers WD, Barrett DM, Wein AJ. Voiding dysfunction: Diagnosis, Classification and Management. In: Adult and Pediatric Urology. Eds: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW. Third Edition, St. Louis: Mosby, 1996:1220-1325. |
|7.||Blaivas JG. Multichannel urodynamic studies. Urology 1984; 23:421. |
|8.||Blaivas JG, Sinha HP, Zayed AA, et al. Detrusor external sphincter dyssynergia. Journal of Urology 1981; 125:541. |
|9.||Kumar S. An anatomical-functional and aetiological classification of lower urinary tract symptoms to facilitate understanding and diagnosis. Indian Journal of Urology 1999; 16: 77-81. |
|10.||Hansen CP, Klarskov P. The accuracy of the frequency-volume chart: Comparison of self-reported and measured volumes. British Journal of Urology 1998; 81:709-711. |
|11.||Bergman A. Office work-up of lower urinary tract dysfunctions and indications for referral for urodynamic testing. Obstetrics and Gynecology Clinics of North America 1989; 16 (4): 787-794. |
|12.||Romanzi LJ, Herttz DM, Blaivas JG. Preliminary assessment of the incontinent woman. Urologic Clinics of North America 1995; 22 (5) 513-520. |
|13.||Turner-Warwick R, Milroy E. A reappraisal of the value of the routine urological procedures in the assessment of urodynamic function. Urologic Clinics of North America 1979; 6 (1): 63-70. |
|14.||Kolman C, Girman CJ. Jacobsen SJ, Lieber MM. Distribution of postvoid residual urine volume in randomly selectted men. Journal of Urology 1999; 161:122-127. |
|15.||Holtgrewe HL. Editorial: Benign Prostatic Hyperplasia. Journal of Urology 1997; 157:184. [PUBMED] |
|16.||Reynard JM, Peters TJ, Lim C, Abrams P. The value of multiple freeflow studies in men with lower urinary tract symptoms. British Journal of Urology 1996; 77:813. [PUBMED] |
|17.||Reddy PS. A comparative study of conventional water cystometry and urinary flow rate versus electronic urodynamics. Indian Journal of Surgery; December 1986: 451-453. |
|18.||Ouslander JG, Leach GE, Abelson S, Staskin DR, Blaustein J, Raz S. Simple versus multichannel cystometry in the evaluation of bladder function in an incontinent geriatric population. Journal of Urology 1988; 140:1482-1486. |
|19.||Ouslander JG, Leach GE, Staskin DR. Simplified tests of lower urinary tract function in the evaluation of geriatric urinary incontinence. Journal of American Geriatric Society 1989; 37:706-714. |
|20.||Turner-Warwick R. Bladder outflow obstruction in the male. In: Urodynamics - Principles, Practice and Application. Eds: Mundy AR, Stephenson TP, Wein AJ. Edinburgh: Churchill Livingstgone, 1984:183-204. |
|21.||Hinman F Jr. Multichannel urodynamic studies: Non-indications. In: Controversies in Neurourology. Eds: Barrett DM, Wein AJ. New York: Churchill Livingstone, 1984:187-190. |
|22.||Ingelfinger FJ. Medicine: Meritorious or meretricious. Science 1978; 200:945. |
|23.||Robertson AS, Griffiths CJ, Ramsden PD, Neal DE. Bladder function in healthy volunteers: Ambulatory monitoring and conventional urodynamic studies. British Journal of Urology 1994; 73: 242-249. [PUBMED] |
|24.||Golomb J. Lindner A. Siegel Y, Korczak D. Variability and circadian changes in home uroflowmetry in patients with benign prostatic hyperplasia compared to normal controls. Journal of Urology 1992: 147: 1044-1047. |
|25.||Griffiths CJ, Assi MS, Styles RA, Ramsden PD, Neal DE. Ambulatory monitoring of bladder and detrusor pressures during natural filling. Journal of Urology 1989; 142: 780-4. [PUBMED] |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]