Picture Gallery 2
ESWL LITHOTRIPTOR – SHOCK WAVE THERAPY FOR KIDNEY STONES
URODYNAMIC STUDY / URODYNAMICS
Part 2
VIDEO-URODYNAMICS
Detrusor Underactivity / Hypotonic Bladder
50 yrs M, no bothersome LUTS symptoms
Detected poor flow with prolonged voiding on screening procedure
No focal neurological deficits, no loss of lower limbs power, no loss of pin-prick sensations, no parasacral paresthesia, good anal tone
Poor flow, low voiding pressures
No bladder outlet obstruction on P-Q plot
Bladder Outlet Obstruction due to Bladder Neck Obstruction
46 yrs M, had poor flow, required catheterization earlier
Detected poor flow on Uroflowmetry
Referred here for Urodynamic Study
No focal neurological deficits, no loss of lower limbs power, no loss of pin-prick sensations, no parasacral paresthesia, good anal tone
Poor flow, high voiding pressures
Bladder outlet obstruction on P-Q plot
Urodynamic findings:
Uroflowmetry:
Qmax 7.1, voided 318ml, PVR 200ml
Urethral pressure profilometry:
MUCP 189 cmH2O
URODYNAMICS:
Filling phase:
FD 310ml
ND385ml
SD 480ml
Stable bladder
Poorly compliant, especially near end filling
Pdet 5cmH2O at 219ml; pDet 31cmH2O at 478ml
EMG – good guarding reflex on filling
Voiding phase:
pUra relaxation during voiding
EMG relaxation during voiding
Qmax 7.9
pDetQmax 81
Vt 108 secs
max pDet 93cmH2O
PVR 150ml
pDet opening 68cmH2O
pDetQmin 50cmH2O
BOOI 65.2 (>>40)
BCI 119 (normal contractility)
BVE 72%
Urodynamic diagnosis:
Bladder outlet obstruction
CYSTOSCOPY:
Gd 1-2 trabeculations
Cannot appreciate bladder neck stenosis
BXO of glans penis+, but urethral calibre normal
DIAGNOSIS:
Bladder outlet obstruction
PLAN:
No need MRI spine
Advised BNI (Bladder Neck Incision) / TURP
Bladder Outlet Obstruction confirmed on P-Q plot and ICS Nomogram
Cystoscopy shows trabeculated bladder
Non- Neurogenic Detrusor Overactivity – Overactive Bladder
No Bladder Outlet Obstruction
47 yrs M, has urgency and urinary frequency
Has weak urine flow
Has history of slip disc mulitple levels
Referred here for Urodynamic Study
No focal neurological deficits, no loss of lower limbs power, no loss of pin-prick sensations, no parasacral paresthesia, good anal tone
Urodynamics
Focal neuro exam – normal
Unstable bladder with hypocontractlie bladder on voiding
No bladder outlet obstruction on P-Q plot
Urodynamic diagnosis: Underactive Detrusor with Detrusor Overactivty on filling phase
Need TRO neurogenic bladder in view of previous spinal problems
Cystoscopy
No evidence of obstruction
Gd 2 trabeculations of bladder
FINAL CLINICAL DIAGNOSIS:
Underactive Detrusor with detrusor overactivity on filling
No DSD features
Summary – 2 pathologies exist:
Hypotonia on voiding
Unstable bladder on filling.
Possibilities:
- Multilevel disc prolapses
- Disc prolapse causing hypotonia, with pre-existing bladder neck obstruction
- Non-neurogenic Overactive bladder with hypotonia
PLAN:
Needs MRI spine and referral to Ortho / Spine surgeon
Symptomatically combination of alpha blockers with anticholinergics will help
