Clinical history: A 60 year old female presents with complaints of urgency, frequency, nocturia, and urgency-related incontinence. Physical exam is notable for a Grade IV cystocele, Grade III uterine prolapse, and Grade II rectocele. No stress incontinence is elicited with reduction of the prolapse. During urodynamic testing the patient reported urgency and a strong desire to void at 185 cc which she attempted to suppress (Fig. 20.2).

This study demonstrates:

Answer 5. Detrusor overactivity without leakage is demonstrated with the rise in detrusor pressure and vesical pressure during the filling phase. No corresponding leakage is recorded by the uroflometer.

The videofluoroscopic image (Fig. 20.3) is obtained in the patient described in Test Question 2.

This demonstrates:

Answer 2. Significant cystocele. The base of the bladder is descended well below the pubic symphysis.

Clinical history: A 55-year-old female with multiple sclerosis presents with complaints of urgency, frequency, nocturia, and urgency-related incontinence. Physical exam reveals normal genitalia without evidence of prolapse. No stress incontinence is elicited with cough stress test. During urodynamic testing the patient reported urgency and a strong desire to void at 79 cc which she attempted to suppress (Fig. 20.4).

This study demonstrates:

Answer 5. Detrusor overactivity without leakage is noted first then detrusor overactivity with leakage is demonstrated with the rise in detrusor pressure and vesical pressure during the filling phase. Corresponding leakage is recorded by the uroflometer.

Clinical history: A 65-year-old white male with a history of Parkinson’s disease presents with a chief complaint of new onset urinary urgency. Urodynamics are shown in Fig. 20.5. He presents with a voiding diary showing volumes of 400–500 mL. Which of the following would be the best next step?

Answer 1. Timed voiding and antimuscarinics. This patient demonstrates poor bladder compliance on his urodynamic tracing. His detrusor leak point pressure is >40 mm H₂O at bladder volumes >380 cc. Therefore, an appropriate next step would be timed voiding. His voided volumes theoretically should be 200–300 cc in order to maintain a normal detrusor pressure. Observation is not an appropriate next step due to the risk of upper tract damage. Alpha-blocker therapy will not improve his abnormal compliance. This patient may ultimately progress and require botulinum toxin injections, but on initial presentation, the least invasive approach should be tried first.

Clinical History: A 30-year-old male with a history of T11 spinal cord injury is managed with CIC four times daily and maximum anticholinergic therapy. His catheterization diary shows volumes of 250–300 mL. His urodynamic tracing is seen in Fig. 20.6. He still complains of urinary leakage between catheterizations. Which of the following statements is false?

Answer 1. The patient is at risk of upper tract damage due to an elevated abdominal leak point pressures during filling. This patient’s tracing shows abnormal bladder compliance and an elevated detrusor leak point pressure during filling. Abdominal leak point pressures are not generally related to the risk of upper urinary tract deterioration but detrusor leak point pressures are related to such a risk. Elevations in detrusor pressure, especially a tonic rise as demonstrated in this tracing, are worrisome for upper tract damage. This patient’s clinical presentation and urodynamic tracing should warrant an upper tract evaluation. A renal ultrasound at a minimum should be performed. This patient would be an excellent candidate to study using videourodynamics to assess for a “pop-off” mechanism. Botulinum toxin injection would be a reasonable next step. However, if his detrusor pressure does not subsequently improve, he may ultimately require an augmentation cystoplasty.

Clinical History: A 68-year-old male with benign prostatic hypertrophy undergoes urodynamics (Fig. 20.7).

The circles in this study represent:

Answer: 1. Involuntary detrusor contractions produce a rise in pressure in the P _ves and P _det leads and not in the P _abd lead. The circles in this study represent detrusor overactivity. This is not detrusor underactivity as this is related to voiding pressures. A provocative maneuver such as coughing would generally appear as a sharp increase in the P _ves and P _abd leads due to the sudden increase in pressure generated with the cough. This does not represent an artifact; an increase in pressure in both the P _ves and the P _det lead in the face of a quiescent P _abd represents a bona fide detrusor contraction. Impaired compliance would appear as a slow increase in the P _det and P _ves signals as the volume in the bladder increases.