Clinical History: Sixty-seven-year-old female with symptoms of mixed urinary incontinence. It is unclear from her history whether her symptoms are predominantly related to stress or urge urinary incontinence. The patient tried Imipramine without benefit and has a 24 h pad weight of 205 g (Figs. 15.4 and 15.5).

Commentary on Example 2: This tracing shows evidence of SUI (Fig. 15.4). First sensation is at 82 mL. Compliance is normal. Capacity is 344 mL. Stress maneuvers were performed at approximately 200 mL and again at 250 mL. These maneuvers demonstrated SUI with a VLPP of 80 cm H₂O at 266 mL. There were no involuntary detrusor contractions. Voiding was assessed with a pressure flow study. This demonstrated a normal bell-shaped flow curve with a peak flow rate of 23 mL/s and a maximum detrusor pressure of 33 cm H₂O. The patient emptied her bladder to completion. Fluoroscopy showed a smooth-walled bladder and a bladder neck that was closed at rest and opens during leakage and voiding (Fig. 15.5).

This patient has SUI.

The study was able to determine the predominant signs of SUI in a setting where the patient had indeterminate symptoms that did not allow us to differentiate between stress and urge urinary incontinence.

For the most part, the quality of this tracing is good. Of note, the catheter changed position about half-way through the study and was readjusted and re-zeroed, indicated by a sharp change in the tracing shown at 133 mL. This commonly occurs during urodynamic evaluations and it does not mean that the study has to be re-started.

Clinical History: Sixty-nine-year-old male with history of myasthenia gravis and urinary incontinence. The patient has a history of a colectomy for colon cancer and has an ileostomy. The urodynamics study was performed in order determine the etiology of his urinary leakage (Figs. 15.6 and 15.7).

Commentary on Example 3: This tracing demonstrates SUI with provocative maneuvers at 74 mL and again at 279 and 306 mL (Fig. 15.6). The tracing shows a CLPP of 69 cm H₂O at 279 mL and a VLPP of 54 cm H₂O at 306 mL. As is often the case in male patients, leakage of urine was visualized at the meatus and on fluoroscopy, but was not captured on the urodynamic tracing. The patient reported no bladder sensation. Compliance was normal and bladder capacity was 306 mL. There was no evidence of detrusor overactivity. The patient was unable to void with the catheter in place, but was able to void for an uroflow examination with a maximum flow rate of 51 mL/s in a sawtooth pattern, indicative of valsalva voiding. Fluoroscopy showed an open bladder neck at rest. The bladder wall was smooth and no vesicoureteral reflux was noted (Fig. 15.7).

This patient has SUI secondary to an open bladder neck and ISD. These findings are most likely attributable to his underlying myasthenia gravis or his prior colectomy.

This tracing was helpful to define the origin of the patient’s SUI. Potential treatment options aimed at restoring the position and function of the bladder neck include a medication trial (e.g., imipramine, duloxetine), injectable therapy to the bladder neck, male sling, or artificial urinary sphincter placement.

The quality of this tracing is good. A rectal catheter was not used because of the patient’s altered anatomy (i.e., colectomy). In this patient, we were able to obtain our clinical answer without the use of this catheter. Additionally, this patient was unable to void with the urethral catheter in place. This is a common occurrence, and in this case, the uroflow was able to give us adequate information.

Clinical History: Sixty-one-year-old female with refractory urinary incontinence. She reports “difficulty delaying urination,” especially when she stands up from a seated position. Twenty-four hour pad weight is >400 g. She has tried imipramine, an antimuscarinic, and estrogen cream in the past, all without any notable benefit. The patient also has a history of a “bladder suspension” that was performed approximately 20 years ago. It is unclear whether she has stress or urge predominant urinary incontinence (Figs. 15.8, 15.9, and 15.10).

Commentary on Example 4: This tracing shows stress maneuvers resulting in the demonstration of stress incontinence (Fig. 15.8). The patient had a VLPP of 106 cm H₂O at 198 mL and a CLPP of 147 cm H₂O at 236 mL. Interestingly, as shown in Fig. 15.9, the stress incontinence induced an involuntary detrusor contraction, resulting in the leakage of a larger amount of urine. Since a Pabd catheter was not used in this study, we can determine that this was an involuntary detrusor contraction based the patient’s sensation of a bladder contraction during this point in the study. This point emphasizes the importance of being present during the urodynamics evaluation in order to correctly interpret the findings. Bladder compliance was normal. First sensation was almost immediate at 7 mL. Bladder capacity was 278 mL. Voiding resulted in a flow pattern that was flattened. Peak flow rate was 12 mL/s and maximum detrusor pressure during flow was 81 cm H₂O. Post-void residual was zero. Pelvic floor muscles relaxed during voiding. Fluoroscopy showed an open bladder neck during leakage of urine (Fig. 15.10).