Indian Journal of Urology
EDUCATION
Year
: 2000  |  Volume : 16  |  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


Santosh Kumar 
 Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India

Correspondence Address:
Santosh Kumar
Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry
India

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).



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;16:183-189


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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 Jan 20 ];16:183-189
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Full Text

 Introduction



Everything should be made

as simple as possible,

but not simpler.

Albert Einstein

(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. [1]

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. [2] Hydrodynamics is the branch of physics that deals with the flow of liquids. [2] 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. [3],[4]

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. [5]

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 [3] 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 [6] 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". [7] 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. [8]

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. [9] 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, [10] urolog [11] or urinary or voiding diary. [12] The name Time Vol­ume Record facilitates its explanation to patients. It meas­ures functional bladder capacity. Turner-Warwick calls it a natural volumetric cystometrogram. [13]

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. [12]

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. [14] 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 [6],[7] 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. [16] Multiple freeflow studies are needed to provide reliable data. [16] Uroflowmetry is stated to be of limited use in the evaluation for benign prostatic hyperplasia. [15]

7. Simple Cystometry

Simple cystometry can be performed either by using a simple water manometer [17] or by using a 50 or 60 ml cath­eter-tip syringe without piston (Eyeball Urodyna­mics). [12],[18],[19]

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.

10. Cystodynamogram

Turner-Warwick developed intravenous urodynamo­gram, intravenous cystodynamogram and ultrasound cystodynamogram. [20] 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, [21] "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.

Santosh Kumar

The specialist who has invested in

expensive diagnostic equipment is

motivated to use that equipment even when

the indications are marginal.

F J. Ingelfinger [22]

 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. [23] These limitations have led to the emergence of trends like home uro­flowmetry [24] and ambulatory urodynamics. [25]

References

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