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No Downloads. Views Total views. Actions Shares. Embeds 0 No embeds. No notes for slide. Urodinamia 1. Committee 7 Urodynamics Chairman Y. Urodynamics Y. LOSE, P. ROSIER vous control mechanisms, central and peripheral as well as somatic and autonomic, integrate these functions Figure 1. Clearly urinary incontinence, represents a failure to store urine adequately, but it can be associated with or aggravated by some types of voiding dysfunction of neurogenic, mechanical or functional etiology.
Failure to store urine at low pressure or emptying at high pressure may affect upper urinary tract drainage and eventually its function. Occasionally, leakage may occur through channels other than the urethra. This is extra-urethral incontinence. In spite of the fundamental importance of urodynamics, the committee has found that for each type of test the evidence is based either on case series level 4 evidence or expert opinion level 5 evidence.
For this reason it has not repeatedly restated the levels of evidence, but has graded each of its final recommendations for clinical practice on the basis of these levels of evidence. Inevitably, one of the principal recommendations is for clinical research studies to improve the quality of the evidence. Urodynamic studies comprise a series of tests. The appropriate test s should be selected and performed in an attempt to answer well-defined question s on the target functions to be evaluated Table 1.
In the case of incontinence, the most relevant of these tests are directly related to the incontinence itself; that is, they aim to demonstrate involuntary leakage in the test setting. Cystometry with or without simultaneous imaging, ambulatory urodynamics and the measurement of leak point pressures are the primary examples of such tests. Other urodynamic tests have an indirect relation to the incontinence.
The information provided by these studies may be useful in establishing etiology and may be clinically important by helping to select the most appropriate intervention. Uroflowmetry, residual urine measurement and pressure-flow studies are examples.
The lower urinary tract is composed of the bladder and urethra. They form a functional unit to store and evacuate urine. During the normal storage phase, as the bladder is filled with urine, a sensation of filling is perceived at a certain moment and subsequently a desire to void is felt. Normally no uncomfortable sensation such as urgency, pain or discomfort is perceived and no urinary leakage occurs.
Competence of the urethra and accommodation of the bladder make it possible to store urine at a low and stable pressure. The low storage pressure insures adequate drainage of urine flow from the upper urinary tract. The normal voiding phase is characterized by the voluntary initiation of micturition followed by forceful and continuous flow with no residual urine.
Coordinated relaxation of pelvic floor and external urethral sphincter as well as detrusor contraction contribute to the efficient emptying of the bladder. Urinary flow can be intentionally interrupted by voluntary contraction of urethral sphincter and pelvic floor.
Ner- In the clinical work-up of an incontinent patient, urodynamic studies are indicated for the following reasons: - to identify or to rule out the factors contributing to the incontinence and their relative importance 4. Figure 1 : Illustrative normal urodynamic findings with fluoroscopic imagings. Intravesical pressure pves , abdominal pressure pabd , detrusor pressure pdet: pves-pabd , urethral pressure pura measured at the point of maximum urethral pressure, Pura-Pves, urinary flow Q and surface electromyography EMG during the storage and voiding phases are idealized.
Cystometry storage function and sensation of the bladder during the filling phase any incontinent subjects to be investigated for their dysfunctional conditions 2. Urethral pressure measurement urethral closing forces subjects suspected of urethral incompetence 3.
Leak point pressure measurement A. Detrusor B. Abdominal urethral competence against pressure generated in the bladder from detrusor or abdominal forces subjects suspected of neurogenic lower urinary tract dysfunction A or urethral incompetence B 4. Uroflowmetry, Residual urine measurement global voiding function any incontinent subjects residual or those suspected of voiding dysfunction uroflow 5. Pressure-flow studies detrusor contractility and bladder outlet obstruction during the voiding phase subjects suspected of voiding dysfunction 6.
Surface electromyography coordinated relaxation of pelvic floor during the voiding phase subjects suspected of dysfunctional or dyssynergic voiding 7. Videourodynamics Simultaneous observation of the morphology and function of the lower urinary tract subjects with suspected multifactorial etiologies for incontinence or anatomical abnormalities of the lower urinary tract 8.
Ambulatory urodynamic monitoring behavior of bladder and urethra and leakage mechanisms during activities of daily living subjects suspected but not proven to have incontinence or detrusor overactivity on conventional investigations 5.
GENERAL - to predict the consequences of the dysfunction for the upper urinary tract The patient should be informed of the procedures before the studies, preferably by written leaflets but in any event by oral explanation. The nature of any such medication and the timing of its administration especially the last dose should be noted.
Medications that affect lower urinary tract function but have been prescribed for other reasons should be taken into account when interpreting the findings. Basically, the urodynamic study should be performed and reported in accordance with the standards of the Inter1 national Continence Society ICS , so as to optimize interpretation and facilitate comparison between different studies.
This principle is applied hereafter; however, the chapter is not intended to simply reproduce the ICS standardization report but rather to focus on the clinical relevance of urodynamics to urinary incontinence.
It includes recommendations for study procedures, interpretation of study results and the ability to predict treatment. Electrophysiological studies are treated in more detail in chapter 4. The subject should be awake and unanesthetized during the study. In children, studies are sometimes performed under mild sedation. However, this is not desirable and can be avoided if the study is thoroughly explained to them beforehand and if care is taken to distract and calm them during the procedure see section III.
The position of the patient during the examination supine, sitting, standing or ambulatory needs to be considered and should be specified in the report. If the position is changed, the pressure transducers if external must be repositioned at the reference level see section I. For example, if incontinence is due to neurological disease, demonstration of leakage during the examination is usually relatively easy, and it may be simplest to examine the patient supine.
This section emphasizes points that are pertinent to all urodynamic studies in the assessment of 2 3 incontinence [2, 3]. These points will be repeated in other sections of this chapter where relevant to the discussion. Further details are available in textbooks . The tasks of the investigator include recognition and minimization of artifacts quality control , communication with the patient regarding sensation and intention, and direction of the whole examination. Quality control requires careful observation of the data as it is being collected.
If data quality problems are identified and corrected at this time, a valid examination may be obtained. If not, the study may be uninterpretable. The investigator should talk to patients in a polite and explicit way to facilitate good communication. This is essential so that the patient understands what the investigator requires and the investigator knows how the patient feels and whether the patient is consciously inhibiting the leakage.
Such information is absolutely necessary to select the appropriate studies and to anticipate what events might take place during the urodynamic investigation. The symbols for these pressures are pves, pabd, pura and pdet, respectively.
Thus, these tasks require diligent scrutiny throughout the progress of the study and understanding of the results while the test is being carried out. Consequently the person conducting the investigations must note and record all relevant events as well as simultaneously interpreting the findings.
Simple inspection of traces after the study is completed does not yield a satisfactory interpretation . To monitor measurement validity, coughing at regular intervals, e. Coughing should consistently give similar pressure changes in pves and pabd Figure 2.
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Study of female urinary incontinence with single channel urodynamics: comparison of the symptoms on admission. Analysis of females. Palabras clave: Incontinencia de orina. Urodinamia monocanal.