• Running water: either by physically turning a tap on in the room producing an audible sound in the sink or playing a recording of a similar sound
• Hand warming and watering: Submerging the patient’s fingers in a bucket with warm water and encouraging a relaxed approach to voiding
• Repositioning: Positioning the patient into the same voiding position that they use when in the non-laboratory setting. For example, some individuals may universally void in the standing or seated position. Accommodation should be available for repositioning of these patients in the urodynamics room. Nevertheless, when such accommodations are made, it is important that the patient is safely able to void without disrupting the wires, urodynamic, or radiographic equipment.
• Physically leaving the room: Some individuals will have great difficulty initiating voiding in the presence of others. Sometimes called “bashful bladder,” voiding can be facilitated in these patients by simply leaving the room. The patient should be reassured that they will be safe alone in the room during this period of time. Use of a remote control marker will allow continued monitoring and recording of events even if not at the urodynamics computer.
• Guided imagery: verbally walking the patient through the scenario of voiding can be helpful in initiating urination.
Urge Suppression Techniques
During the study, the goal is to reproduce the symptoms experienced by the patient as at home. By comparing the presentation of the symptoms in the lab with the objective data recorded in a voiding and/or catheterization diary, the clinician can direct the study in order to reproduce symptoms. With the introduction of catheters and an un-physiologic filling rate, the patient may experience multiple involuntary bladder contractions (IBCs) that do not correlate with physiologic capacity and/or their normal sensations of urgency.
An important point is that directing the patient to attempt to suppress incidental detrusor contractions may afford the clinician with important data which is not only diagnostic, but potentially therapeutic. The sensation of urgency is annotated on the tracing and, if coincident with an IBC, this is recorded as well. The clinician then can ask the patient to suppress the urge as they would at home and label this event on the tracing. This maneuver will help to evaluate if the patient can inhibit the involuntary contraction, which can serve as a future basis for therapeutic pelvic floor muscle training with the goal of urge suppression. In addition, if the patient inappropriately recruits abdominal muscles during attempted suppression, as indicated by a rise in the abdominal pressure recording, then they can be educated, using this biofeedback technique, in the proper performance of pelvic floor muscle isolation and recruitment. The EMG activity seen coincidently with the proper performance of a pelvic floor contraction can aid in teaching the patient about their pelvic floor as an additional form of biofeedback. In the event the patient is unable to suppress the IBC, the clinician can teach the patient various urge suppression techniques. One such technique is to instruct the patient to “squeeze the pelvic floor as if they were trying to prevent passing gas”. An alternative maneuver for the patient who is unable to isolate the pelvic floor muscle is the “heel click” maneuver. In order to do this action, the patient is instructed to click the heels in place while keeping the feet planted on the floor. This action, when done correctly, will elicit a rise in the EMG recording without a rise in the abdominal pressure lead. This phenomenon is demonstrated in Fig. 7.1.
Fig. 7.1
This pressure-flow urodynamic tracing demonstrates involuntary bladder contraction. The patient then attempted a long sustain pelvic floor contraction, but then was taught how to do heel clicks to suppress subsequent contractions
Finally, it is important to periodically reassess the signal quality of the UDS equipment during the study. This can be done by having the patient perform a stress maneuver such as a valsalva, or cough, and compare the expected changes in the vesical, abdominal, and EMG leads to that at rest.
Medication Management
Antibiotic Prophylaxis
The American Urological Association has issued a Best Practice Policy statement for antimicrobial prophylaxis [4]. This evidence-based document reviews surgical antimicrobial prophylaxis for a variety of urological procedures and states that “An important change in antimicrobial prophylaxis pertaining to urologists is that antimicrobials are no longer recommended by the American Heart Association in association with genitourinary procedures solely to prevent infectious endocarditis [4].” The panel reviewed current research and recommended that antimicrobial prophylaxis for urodynamic studies is not necessary if the urine culture prior to the procedure is negative. If coverage is indicated for individualized clinical scenarios (i.e., the severely immunosuppressed patient), the drug of choice is a fluoroquinolone or trimethoprim-sulfamethoxazole for a 24 h duration. Positive cultures should be treated with appropriate antibiotic coverage. Of note, the US Food and Drug administration (FDA) has released a statement that patients should be notified about the possible risk of permanent peripheral neuropathy associated with the oral or intravenous use of fluoroquinolones [4]. The principle of not treating urine unless there is growth noted on culture also applies for the removal of an external urinary catheter and for the patient undergoing clean intermittent catheterization, which also may apply to this population. Urine culture and appropriate antibiotic coverage is recommended prior to study if infection is suspected in this population.
Other “Premedications”
Patients undergoing video urodynamics are infused with a contrast agent. Such agents are associated with allergic reactions, and anaphylaxis in a small number of individuals when infused intravenously or when these agents gain access to the systemic circulation. Whether allergic reactions are relevant to bladder filling during video urodynamics is unclear in the absence of a traumatic catheterization. In patients with a shellfish allergy, iodine allergy, or a known contrast allergy, video urodynamics should be done with caution and with appropriate preparation. When possible, the use of non-ionic contrast agents, and a prophylactic steroid and antihistamine regimen starting 24 h prior to the study may reduce or eliminate systemic reactions.
Premedication for neurogenic patients and potential autonomic dysreflexia is discussed in Chap. 9: Special Considerations in the Neurogenic Patient.
Other Challenging Situations Related to UDS Testing
Catheterization
Difficult catheterization can impede the study from the beginning. It is important to recognize that many individuals presenting for UDS have an anatomically abnormal lower urinary tract such as that due to stricture or contracture. This may result from prior surgery, trauma, infection, or other urological conditions. Other individuals are simply very anxious and will volitionally contract the external sphincter either in response to the anticipation or pain of urethral manipulation making catheterization increasingly difficult. Interventions for these situations are varied and although the first catheterization to empty the bladder is often successful, subsequent catheterization with the smaller urodynamics catheters for the pressure-flow study may be difficult.
At times, the use of urethral anesthetics, such as lidocaine infused lubrication gel, prior to catheterization may be beneficial and provide some comfort to both men and women during the catheterization process. Siderias et al. [5] conducted a randomized controlled trial of males in the emergency department and concluded that topical lidocaine gel reduced pain as compared to topical non-medicated lubricants during urethral catheterization. A similar study was also conducted comparing water-based lubricating gels with lignocaine gel in the female population requiring catheterization in the emergency department. This randomized controlled trial found that the lignocaine gel reduced procedural pain for urethral catheterization [6]. Although these studies are not directly related to the traditionally non-emergent setting of urodynamics, the use of anesthetic gels may provide a less painful catheterization. Gels also provide gentle atraumatic dilation of the urethral lumen, which may ease subsequent catheterization.
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