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Filling Cystometry

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					Cystometry
Dr. Abdelazim Hussein Khalafalla Ass . Professor Urology Department National Ribat University

Cystometery

Filling cystometry

Voiding cystometery

Ability to store

Efficacy of Emptying

Filling Cystometry
• Measures the pressure/volume relationship of the bladder (Measurement of detrusor pressure
during controlled bladder filling)

• filling medium either gas (CO2) or liquid (water, saline, or contrast material at body temp). • liquid cystometry is more physiologic. • ideally, filling should be performed in standing position.

Detrusor pressure
• Cannot be measured • It is estimated/calculated by the automatic subtraction of rectal pressure (an index of IAP) from the total bladder pressure, thus removing the influence of artefacts produced by abdominal straining Pdet = Pves - Pabd

Filling Cystometry Failure to store

Bladder

Outlet

1. Overactivity

1. ISD
2. hypermobility

2. hypersensitivity

3. Combination

Filling Cystometry: Aim
Used to assess
1. 2. 3. 4. Bladder sensation, Detrusor activity, Bladder capacity, Bladder compliance,

5. Outlet incompetence.

Filling Cystometry: Technique
• Patient preparation:
History and Examination MUS Explain the procedure Voiding Catheterization Measure the residual urine

• Patient may be investigated supine, sitting or standing.

Filling Cystometry: Technique
• • • • • The transducers are calibrated. Zero setting. Connect the catheter to the cystometer. Start recording and infusion. Instruct the patient to report (FD), strong desire to void, urgency, cystometric bladder capacity (CBC)

Filling Cystometry: Technique
• The patient is asked to cough every minute during filling and after voiding to ensure that the catheters have not become displaced during micturition. • If the spikes are not identical, lower traces, then the explanation maybe :
– – – – There are bubbles or Leaks, Catheters are mal-positioned Interference with the measurement of pabd due to faecal loading.

• All these points must be checked and the cough repeated until the proper pattern is observed.

Filling Cystometry: Technique
Pabd

Pves

Vinfus

Filling Bladder

Pump
Pves Pabd

Recording Bladder Pressure Reaction during Filling With Control of Abdominal Pressure

Pressure Transducers

Filling Cystometry: Technique

Pves Pressure P ves Proximal Transducer

Filling Line Peristaltic Pump

Filling Cystometry: Out Put
• Curves (Traces) • Results (Table) • Report (Word)

Filling Cystometry: Results

Events

Pdet
cmH2O

Volume
ml

Compliance
ml/cmH2O

Basic Pressure First Desire Normal Desire Strong Desire Urgency Max Cysto. Capacity

BP FD ND SD UR CC

3 7 12 21 30 32

20 160 270 440 575 610
35 22 19 15

20 18

Filling Cystometry: Traces interpretation
Principles

• If a change is seen in both Pves and Pabd but not in Pdet, then it is due to raised IAP.
• If a pressure change is seen on Pves and Pdet and not on Pabd, then it is due to a detrusor contraction. • If a change is seen on Pves, Pabd and Pdet, then there is both a detrusor contraction and raised IAP. • If a pressure change is seen on pabd with no change in pves and a consequent fall in pdet then this due to a rectal contraction.

Filling Cystometry: Traces interpretation
Post void residual urine • Post void residual urine above 300 ml, who have a pressure Rise at end pressure above 25-30 cm H2O, carry a risk of more than 50% of developing dilatation of the upper urinary tract. • In-and-out catheterization has been regarded as the gold standard. • Transabdominal ultrasonography is non-invasive and the method of choice, based on calculations using different formulas (an example is 0.5 x length x height x width of the bladder).

Filling Cystometry: Traces interpretation
Pitfalls of PVU • A delay time between voiding and measurement is the most frequent cause of a false positive • Voiding in unfamiliar surroundings, • Voiding on command, • A partially filled or overfilled bladder, • Vesicoureteric reflux • Bladder diverticula, • Inproper catheter emptying technique,

Filling Cystometry: Traces interpretation
1-Bladder sensation • In a normal bladder, first desire often occurs at a bladder volume of 100-400 ml, depending on the filling rate, position and catheter used. • FD < 100 --- Bladder hypersensitivity • FD > 400 --- Patient never experiencing a strong desire to void -------Reduced sensation

Filling Cystometry: Traces interpretation
• Absent sensation ----indicative of a neurological
condition such as spinal cord trauma

2-Detrusor Activity
The normal detrusor remains quiescent during filling and detrusor overactivity does not occur under any circumstances (e.g., during the provocation tests(Provocative Cystometry) used in an effort to uncover detrusor overactivity (DO))

Provocative Cystometry Provocative cystometry involves a series of triggering procedures aiming to elicit reflex detrusor activity. Physical Provocation -Rapid bladder filling (>100 ml/min), -Jumping up and down , -Coughing, -leaning forward, - changing posture (from supine to sitting or standing), -Crede maneuver (suprapubic tapping) may help trigger unstable detrusor contractions.

Filling Cystometry: Traces interpretation
3-Bladder capacity, • The normal bladder capacity is in the range of 300 to 500 mL; • Cystometric bladder capacity (CBC) if the resting pressure reaches 30 cm H2O • In infants and in some neuropathies CBC can be taken as the volume at which the patient starts voiding.

Filling Cystometry: Traces interpretation
4-Compliance:
• Normal bladder is highly compliant,and can hold large volumes at low pressure. • Compliance is the change in volume divided by the change in detrusor pressure during that change in bladder volume and is expressed as ml/cm H2O (C = V / pdet). 12-29 ml/cmH2O • Normal pressure rise during the course of CMG in normal bladder will be only 6-10 cmH2o. • Decrease compliance = > 20 ml/cmH2o, poorly distensible bladder. • Increase compliance

Filling Cystometry: Traces interpretation
5. Outlet incompetence. - competent - incompetent

Voiding Cystometry
EMG Pabd Pves Qura

Pves Pabd EMG Qura

Recording Bladder Pressure Abdominal Pressure Electromyography during Voiding Phase

Voiding Cystometry
Patient
In sitting position
Ask the patient to void without straining

Equipment
Transducers Bladder level Flow rate Sensitivity 5 ml/sec. EMG Sensitivity 10 µV.

VOIDING CYSTOMETRY. l
EMG

Pves

Pabd

Pdet

Qura

VB

QM

PM

Vura

VE

Time 10 sec/Div

Voiding Cystometry.
EMG

DSD

Pves

Pabd

Pdet

Qura

QM

VB

PM

Vura

VE

Time 1 min/Div

C

FS

ND

S D UR CC

Normal filling cyst

FS UR

ND

SD

Increased BL sensation

Reduced sensation

Absent sensation 1. Sensation “sensation against volume”

No involunatry det contration

2. Detrusor function

Pdet 60

Terminal DO

Phasic DO

No increase in Pdet

500

CC

3. Compliance

Steady increase Det P

250

low compliance

CC

4. Cystmetic bladder capcity

DOV

Decreased compliance

hypersensitivity

Decrease Max CC

Urgency, frequency, nocturia

Leak

Each Phasic DO

U

U

Phasic detrusor overactivity incontinence

Involuntary voiding

Terminal Involuntary DO

Terminal detrusor overactivity incontinence

Involuntary voiding

Terminal Involuntary DO

Terminal detrusor overactivity incontinence

No increase Det P

leak

Urodynamic Stress incontinence

No increase Det P

leak

Urodynamic mixed incontinence

Filling Cystometry: Traces interpretation

Pabd

Pves

Pdet

Cystometry trace showing the patient straining (S), a cough superimposed on an involuntary detrusor contraction (C + U) and an involuntary detrusor contraction (U).

Pves Pabd

Pdet

Rectal contraction: characterised by a positive wave on the pabd trace and a negative artefact on the pdet trace.

Pitfalls in Cystometry
Causes of artifact in cystometry 1. Pressure measurement artifacts
Air bubbles,
Kinked tubing, Incorrect placement of the pressure catheters, Migration of the pressure catheters

2. Infusion rate artifacts (especially in neurogenic bladder)

3. Patient-related issues,
Lack of cooperation, Outlet incompetence, Vesicoureteral reflux .

Report Writing
• • • • 1. 2. 3. 4. 5. 6. Click on report icon. Word sheet will be displayd. Fill data on the space. Using the traces & result write down :Bladder sensation, Detrusor activity, Bladder capacity, Bladder compliance, Outlet incompetence. PVU.


				
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