CHAPTER 11 Committee 7 Dynamic Testing Chair D. GRIFFITHS (USA) Co-chair A. KONDO (JAPAN) Members S. BAUER (USA), N. DIAMANT (CANADA), LIMIN LIAO (CHINA), G. LOSE (DENMARK), W. SCHÄFER (USA), N. YOSHIMURA (USA) Consultant H. PALMTAG (GERMANY) 585 CONTENTS A. INTRODUCTION ABBREVIATIONS BOO bladder outlet obstruction BOOI bladder outlet obstruction index, previously known as AG number B. MECHANISMS OF URINARY BPE benign prostatic enlargement CONTINENCE AND BPO benign prostatic obstruction DHIC detrusor hyperactivity with impaired INCONTINENCE contractile function DO detrusor overactivity DOI detrusor overactivity incontinence C. URODYNAMICS: NORMAL EMG electromyogram/electromyography VALUES, RELIABILITY, AND FDV first desire to void FSF first sensation of filling DIAGNOSTIC AND ICS International Continence Society THERAPEUTIC IPSS International Prostate Symptom Score ISD intrinsic sphincter deficiency PERFORMANCE LPP leak point pressure LUT lower urinary tract LUTS lower urinary tract symptoms D. CLINICAL APPLICATIONS Max Cap maximum cystometric capacity OF URODYNAMIC STUDIES MRI magnetic resonance imaging MUP maximum urethral closure pressure NDV normal desire to void NPV negative predictive value (see section C.IV.1) E. DYNAMIC TESTING FOR OAB overactive bladder syndrome/symptoms FAECAL INCONTINENCE POP pelvic organ prolapse PPV positive predictive value (see section C.IV.1) PVR post-void residual urine (volume) SD standard deviation SDV strong desire to void F. CONCLUSION SEM standard error of the mean SPECT single photon emission computed tomography SPT specificity (see section C.IV.1) STV sensitivity (see section C.IV.1) TURP transurethral resection of the prostate REFERENCES TVT tension-free vaginal tape USI urodynamic stress incontinence VLPP Valsalva leak point pressure 586 Dynamic Testing D. GRIFFITHS, A. KONDO S. BAUER, N. DIAMANT, LIMIN LIAO, G. LOSE, W. SCHÄFER, N. YOSHIMURA H. PALMTAG Following this introduction, and an explanation of A. INTRODUCTION the definitions of the various types of urinary incon- tinence and their corresponding urodynamic obser- vations, the chapter contains a fundamental discus- sion of the two main types of urinary incontinence I. GENERAL REMARKS (stress and urge), a review of data about normal values and reliability of urodynamic parameters, reviews of the literature regarding clinical urodyna- This chapter on “Dynamic Testing” is the successor mic evaluation of different patient groups with uri- to the chapters on “Urodynamic Testing” in the two previous consultations. [1,2] The name change nary incontinence (women, men, children, neuroge- reflects the inclusion of a new topic, faecal (or anal) nic dysfunction, and the frail elderly), a section on incontinence. In the section on faecal incontinence, dynamic testing in faecal incontinence, and finally the available functional tests, their applications in the committee’s recommendations regarding dyna- various groups of patients and types of faecal incon- mic testing. tinence, and the evidence for their clinical utility, are reviewed in as much detail as is practicable. For uri- II. HISTORICAL BACKGROUND nary incontinence, reviews of this sort appeared in the two previous consultations. [1,2] In this 3rd consultation we have updated the evidence for the 1. WHAT IS URODYNAMICS? reproducibility and reliability of urodynamic measu- The conventional view – implicitly adopted in the rements, and the evidence for their clinical utility. previous consultations – is that urodynamics is a The primary aim of the chapter however is to reas- series of more or less agreed-upon clinical tests, such sess the functional and anatomic mechanisms of uri- as filling cystometry and pressure-flow studies, and nary continence, to discuss what urodynamic tests that all that remains to be done is to establish which ought to be performed to elucidate these mecha- tests have clinical utility and in what circumstances. nisms; and to make recommendations for what tests Urodynamics is defined by the International Conti- should be performed and when. Thus we have tried nence Society (ICS) however as the study of the to present a critical view of the role of urodynamics, function and dysfunction of the urinary tract by any the current state of urodynamic assessment, and appropriate method [emphasis added]. [3] Accor- recommendations for the future. ding to this definition, urodynamics is the only way In this chapter, therefore, faecal (anal) and urinary of understanding why people are continent or incon- incontinence are addressed rather differently. Yet in tinent, because the attempt to gain that understanding fact the 2 topics clearly have much in common, in is what constitutes urodynamics. Therefore urodyna- regard to both pathophysiological mechanisms and mics occupies a central place in this consultation. It clinical application. In future consultations we is the pivotal link between basic science on the one expect a more integrated approach to emerge and hand and clinical reality on the other. It can answer yield fruitful insights. questions such as: How does the normal person stay 587 continent? What really goes wrong when they beco- 3. WHAT SHOULD BE THE ROLE OF URODYNA- me incontinent? These questions can be posed as part MICS IN CLINICAL PRACTICE? of clinical or animal research, but they are important in individual patients too. Conventional urodynamic There is general agreement among experts that the testing may not be necessary in every patient, but immediate aim of urodynamic testing is to reproduce making the appropriate measurements remains the the symptom(s) of the patient under controlled and only way of knowing what urinary tract function is. measurable conditions, so that the cause of the symp- Treatment that is not carried out blindfolded but is toms can be determined. Certainly, if the symptom is based on knowledge requires urodynamics. not reproduced the test can be regarded as a failure (although failure to understand the symptoms may 2. WHAT HAS URODYNAMICS ACCOMPLISHED? also contribute). Conceptually, reproduction of the symptom allows diagnosis, helps inform treatment Since urodynamics entered clinical consciousness 40 choice, and improves treatment outcome. years ago, its main achievement has been to focus attention on neuromuscular function and dysfunc- Urodynamic studies provide an objective description tion, especially as embodied in the concept of detru- of lower urinary tract function and dysfunction in sor overactivity. To a considerable extent this has terms of qualitative and quantitative variables. Thus been useful. For example, it is now universally reco- ideally they should provide objective information gnized that stress incontinence is not the only pos- useful for the clinician: sible reason for urine loss in an otherwise healthy a) to identify or to rule out factors contributing to the middle-aged female, and that surgery is not the only incontinence and assess their relative importance treatment. Drug and behavioral treatments, aimed at correction of function, have been greatly enhanced, b) to obtain information about other aspects of lower as demonstrated in the chapters on pharmacotherapy urinary tract dysfunction and conservative management in this book. A less c) to predict the consequences of lower urinary tract desirable consequence has been that attention has dysfunction for the upper urinary tract been directed away from gross anatomy and structu- d) to predict the outcome, including undesirable side ral issues, so that understanding of the anatomical effects, of a contemplated treatment and mechanical basis of stress incontinence has advanced very slowly. In spite of the deeper unders- e) to confirm the effects of intervention or unders- tanding of dysfunction provided by urodynamics, tand the mode of action of a particular type of treat- numerous studies have demonstrated only weak cor- ment, especially a new one relations between symptoms and urodynamic fin- f) to understand the reasons for failure of previous dings, and there has been little objective evidence treatments for incontinence that doing urodynamics – and selecting treatment options on this basis – improves clinical outcomes. In Urodynamic studies should be performed and repor- the previous consultation, accordingly, the evidence ted in accordance with the standards of the Interna- for clinical utility was judged not particularly cogent, tional Continence Society [4] to optimize interpreta- and a rather limited clinical place was suggested for tion and facilitate comparison between different stu- urodynamic testing, especially in women. [1] dies. The conventional view is that urodynamic investiga- Main recommendations for urodynamics in cli- tion ought to provide a gold standard for assessing nical practice according to the previous incontinence. However there is still a pressing need Consultation (ICI 2000) [1]: scientifically to conceptualize continence function in terms which can be measured urodynamically. Ideal- • Investigation should only be performed in ly the chosen variables should fulfill several require- women if voiding difficulty or neuropathy is ments: 1) measurements should be standardized; 2) suspected, if previous surgical or non-surgical results should be reproducible; 3) parameters for treatments have failed, or if invasive or surgical health and disease should be specific and sensitive treatments are considered. with clear cut-off levels and without too much over- • In men and children, detailed urodynamic lap, so as to give clinical