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Daniel Simanjuntak
Samuel Aji
Enrico Saut
Urodynamics
URETHRA
• Closure pressure must
exceed bladder
P pressure
• Reflex closure
Voiding
BLADDER
• Coordinated contraction
causes rise in pressure
P • Complete emptying
URETHRA
• Relaxation
P
bladder)
Pressure (in
Normal filling & voiding
Volume
Urodynamics – spectrum of tests
Simple urodynamics Complex urodynamics
• Freq – volume charts • Urethral pressure
• Pad testing measurement
• Uroflowmetry • Neurophysiological
• Cystometry investigations
• Videocystometrography • Upper tract
urodynamics (e.g. the
• Ambulatory urodynamics
Whitaker Test)
Indikasi dan Seleksi Pasien untuk Dilakukan Urodinamik
Pasien dimana terapi potensial dapat merugikan sehingga urolog harus memastikan bahwa
diagnosa yang ditegakkan sudah benar
Pasien dengan inkontinensia rekuren dan direncanakan akan dilakukan operasi
Pasien dengan inkontinensia dan campuran yang membingungkan antara simptom stres
dan urgensi dan yang berhubungan dengan masalah voiding
Pasien dengan kelainan neurologis dan yang membingungkan antara gejala dan penemuan
klinis.
Pasien dengan LUTS sugestif obstruksi bladder outlet
Pasien dengan LUTS persisten walaupun terapi yang seharusnya sudah diberikan
Pasien dengan LUTS yang memiliki gejala obstruktif dan instabilitas yang signifikan
Pasien dengan LUTS obstruktif dan penyakit neurologis
Orang muda dengan LUTS
Semua pasien dengan cacat neurologis yang memiliki disfungsi buli neurogenik
Anak-anak dengan urgensi pada siang hari dan inkontinensia tipe urgensi
Anak-anak dengan enuresis diurnal yang persisten
Anak-anak dengan dysraphism spinal (Kelainan-kelainan saraf yang menyebabkan kandung
kemih rusak)
INVESTIGATION SYMPTOMS POSSIBLE DIAGNOSIS
Urethral closure
Incontinence Genuine stress incontinence
pressure
• Wanita: uretra yang sangat pendek, tahanan outlet yang minimal, tidak
ada prostat dan secara umum satu-satunya faktor yang mempengaruhi
uroflow pada wanita adalah kekuatan otot detrusor dan resistensi uretra
dan derajat relaksasi sfingter.
• Pada wanita normal, Qmax dapat lebih besar dari 30 mL/detik, kurva
berbentuk sama seperti pada pria, dan flow time lebih pendek.
• Flow max pada wanita tidak tergantung umur.
Key parameters
• Voided vol. > 150 ml
Multichannel filling
cystometrogram shows
detrusor overactivity with
multiple contractions. Patient
had idiopathic detrusor
overactivity. C Vol, volume
infused; Pabd, abdominal
pressure; Pdet, detrusor
pressure; Pves, intravesical
pressure.
4 simple questions
DV = Desired Voiding
Detrusor activity
• During filling this can be either normal or
increased (overactivity)
• Detrusor overactivity exists, when, during the
filling phase, there are involuntary detrusor
contractions
Measurements during voiding
• Premicturition pressure - the pressure recorded just
before the initial isovolumetric
contraction
• Opening time - time between initial rise in
detrusor pressure to the onset of flow
• Opening pressure - pressure recorded at the onset
of measured flow
• Maximum pressure - max value of measured
pressure
• Pressure at max flow - pressure recorded at Qmax
Pressure – flow plots/ Pressure Flow Studies
• The only test that can distinguish between BOO and detrusor
hypocontractility and should be done prior to surgery under certain
circumstances :
- Voided vol < 150 mL in repeated uroflowmetry
- Qmax of uroflowmetry > 15 mL
- LUTS in men > 80 years
- Post-void residual urine > 300 mL
- Suspicion of neurogenic bladder dysfunction
- After radical pelvic surgery
- After unsuccessful invasive BPH treatment
• The Abrams Griffiths nomogram was devised as the best method for
separating the pressure flow loops
The assessment of prostatic obstruction from urodynamic measurements and from residual
urine.
Abrams PH. Griffiths DJ . British Journal of Urology. 51(2):129-34, 1979
EMG,
electromyogram;
Pabd, abdominal
pressure; Pves,
intravesical
pressure; UroPV,
filling volume.
• Sex specific
Pressure-flow loops with Abrams & Griffith
nomogram
Low pressure high flow. The normal urethra is Unobstructed pressure Flow loop. The tip of the
highly distensible and opens at low pressures. loop is well into the unobstrcuted zone.
High pressure low flow; if the normal detrusor is Note that this is displayed on a different scale
obstructed to give low flow rates it will produce because of the high detrusor pressure. The
high pressures. patient is highly obstructed.
Normal / stable bladder
Stable bladder able to accommodate about 500 cc of fluid without significant rise in detrusor pressure
Unstable bladder
Detrusor normal diisi perlahan menerima 300 – 600 cc tanpa kenaikan tekanan. Apabila buli melalui kontraksi fasik di saat pasien mencoba
melakukan miksi, ini dinamakan Detrusor overactivity. Note the low bladder capacity
Schafer Method
Schafer's method for determining urethral resistance is based on consideration
of the urethra as a distensible tube with a flow-controlling zone, the proximal
urethra.
The ICS Provisional Nomogram