Investigations of Female Lower

Urinary Tract Symptoms

(F – LUTS)

Dr Ismaiel Abu Mahfouz

Investigations

Advanced

• Urodynamic studies

• Surface Electromyography

• Urethral pressure profilometry

• Imaging studies

• Cystourethroscopy

Basic

• Urine test

• Bladder diary

• Pad test

Basic investigations

• Urine test

• Bladder diary

• The Pad test

Urine test

The Bladder Diary

• Daytime urinary frequency

• Nocturnal frequency/nocturia

• Twenty-four-hour frequency

• Twenty-four-hour urine production

• Maximum voided volume

• Average voided volume

• Median functional bladder

• Polyuria: (> 40 ml/kg in during 24 hr or 2.8 L)

• Nocturnal urine volume

• Nocturnal polyuria (>30% of 24 H urine production)

Advanced investigations

• Urodynamic studies (UDS)

o Conventional UDS

o Videocystourethrography (VCU)

o Ambulatory Urodynamic Monitoring (AUM)

• Surface electromyography (EMG)

• Urethral Function tests

• Imaging studies Ultrasound scan

Contrast studies

MRI

• Cystourethroscopy

Urodynamics Studies (UDS)

Why?

Urodynamics Studies (UDS)

• Free flow study

• Filling Cystometry

• Voiding cystometry

Uroflowmetry

• Simple

• Non-invasive

• A Record of voided volume and flow rate

The definition of “Normal study”

o Peak flow rate >15ml/sec

o Voided volume >150ml

o PVRV <100 mls

Free flow study

Normal Straining

Detrusor under-activity

Filling Cystometry • Measurement of the detrusor pressure / volume

relationship

• Assess: Bladder sensations, compliance, capacity

• Filling medium: saline, contrast at room temperature

• Filling rate: ? (Weight/4) / min

• Standing positions

• Short, flexible, small (8F) catheters

• Sealed system, no leak, no air bubbles

Urodynamics

Urodynamics

Detrusor overactivity (DO)

Detrusor over-activity incontinence

(DOI)

Cough

DO

Voiding cystometry (Pressure flow studies)

The relationship between detrusor pressure and flow rate

• Obstruction High detrusor pressure (>50 cmH20)

Poor flow (<15 mls/sec)

• Under-active detrusor function Low detrusor pressure (<20 cmH20)

Poor flow (<15 mls/sec)

Urodynamic diagnoses • Detrusor overactivity (DO)

A urodynamic observation characterised by involuntary

detrusor contractions during the filling phase which may

be spontaneous or provoked

• Detrusor overactivity incontinence (DOI)

DO associated with urine leakage

• Urodynamic stress incontinence (USI)

Involuntary leakage of urine during increased abdominal

pressure, in the absence of a detrusor contraction

• Mixed urodynamic incontinence

DO and /or DOI + USI

Vediocystourethrography (VCU)

VCU: Advantages, Disadvantages

Advantages:

Simultaneous visualisation of the lower urinary tract

• Trabiculation, Diverticulae, Filling defects

• VU Reflux VCU

• Position of bladder neck in relation to pubic symphysis

• Bladder neck closure during rest and stress

• Fistulae (Vesico-vaginal / uterine, urethro-vaginal )

• Vesico-ureteric reflux

Disadvantages:

• X-ray exposure

• Expensive

• Allergic reaction to contrast media

Diverticulae

Trabeculation Ureteric reflux

Ambulatory Urodynamics Monitoring

(AUM)

Ambulatory urodynamic monitoring

(AUM)

Indications • Failure to reproduce LUTS on UDS

• No response to anti-muscarenics (Question the Dx)

• Failed repeated incontinence operations

• Neurogenic dysfunction

AUM • More accurate assessment of LUTS

• Conventional UDS more sensitive in the diagnosis of USI

• AUM more sensitive in diagnosing DO

Urethral Pressure profilometry

(UPP)

Urethral Functions

• Filling Urethro-cystometry

• Voiding Urethro-cystometry

Urethral Function Tests

Indications

• Voiding difficulties

• Failed prior continence surgery

• Prognosis following continence surgery

Surface Electromyography (EMG)

Surface Electromyography (EMG)

• EMG of the urethra, anal sphincters or the pelvic floor

• Established method for LUTS evaluation

The normal EMG pattern

• Progressively increasing EMG activity during filling

(guarding reflex),

and

• Timely relaxation of the pelvic floor during voiding

Normal EMG

Imaging studies

• Ultrasound scan

• Contrast studies

• Magnetic resonance imaging (MRI)

Ultrasound in urogynaecology • Perineal . Introital . Trans-vaginal .Trans-abdominal

Uses

• Bladder neck descent/mobility/opening

• Post-void residuals

• Pelvic pathology (ovarian , uterine)

• Bladder abnormalities (tumour, foreign body)

• Urethral abnormality (diverticulum)

• Urethral sphincter, levator ani anatomy

• Endoanal sonography

• Bladder wall thickness

BWT in female urology

• Applications for BWT in Urogynaecology

o Voiding dysfunction

o OAB symptoms

• Increased BWT is associated with DO

5 mm cut-off for BWT in diagnosing DO

Sensitivity 40% - 84%

Specificity 78% - 89%

• BWT and the urodynamic diagnoses:

Statistically significant differences in the mean BWT in

women with DO, MUI and USI (DO>MUI>USI)

Contrast studies

• Videocystourethrography (VCU)

• Intravenous urography (IVU)

• Micturating cystourethrogram (MCU)

Intravenous urography (IVU)

Provides anatomical outline of the urinary tract including a

nephrogram, calyces, renal pelvis, ureter, bladder

Micturating cystogram (MCU)

Principal uses, detection of:

• Vesico-ureteric reflux

• Fistulae

• Diverticulae

Trabeculation VU Reflux

Cystourethroscopy

• Rigid or flexible

• Study anatomy

• Visualisation:

o Calculi

o Tumours

o Diverticulae

• Biopsy of urothelium

o Inflammation

o Cancer