Urodynamic Testing: Complex

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Chapter 252 Urodynamic Testing: Complex

DESCRIPTION

Complex urodynamic testing involves measurement of bladder function carried out with the use of specialized equipment or techniques.

INDICATIONS

Urinary incontinence (stress, urge, mixed, overflow). May be used as an adjunct to the evaluation of interstitial cystitis or other urinary complaints.

CONTRAINDICATIONS

Active bladder infection. Known or suspected allergy to cleansing solutions or local anesthetics to be used.

REQUIRED EQUIPMENT

• Sterile gloves, antiseptic solution and sterile cotton balls, or skin preparation swabs

• Sterile urine specimen cup (with graduations)

• 12- or 14-French straight catheter

• 1 L of sterile saline (intravenous fluid without glucose is generally used) at room temperature

• 2% lidocaine jelly in mushroom-tipped syringe (optional)

• Intravenous or pump tubing (based on the specifics of the equipment used)

• Absorbent underpads

• Urodynamics testing unit (includes recording device, fluid pump, catheter puller, uroflowmetry commode)

• Printer for urodynamics reports

• An assistant is advantageous

If Cystoscopy Is To Be a Part of the Procedure

• Cystoscope (rigid or flexible, direct viewing or with a 30-degree or greater down-angle view; the latter is better for visualizing the bladder trigone and ureteral openings)

• Fiberoptic light source (compatible with type of cystoscope used)

• Fiberoptic light cord

TECHNIQUE

Immediately before the procedure is started, the patient is asked to empty her bladder (in private and in her usual manner). The patient is placed in the dorsal lithotomy position, and the external urinary meatus and surrounding vulvar vestibule are cleansed with antiseptic solution. One to three milliliters of topical anesthetic, such as 2% lidocaine, are introduced into the urethra.

With sterile technique, the patient is catheterized by use of a straight catheter, and any residual urine is caught, measured for volume, and sent for culture (if appropriate). The catheter is then removed.

A catheter-tip microtransducer or other pressure-recording catheter (specific to the equipment being used) is introduced into the bladder to record bladder and urethral pressure. A reference catheter is placed either in the vaginal or rectal canal to infer intra-abdominal pressure. These catheters are secured by tape to the patient’s thigh and attached to the urodynamics unit. The bladder is filled in a controlled manner (approximately 50 mL/min) using the pumping system supplied with the urodynamics equipment. The patient’s first sensation of bladder fullness, the occurrence of a sense of urgency, and maximal bladder capacity are noted, and the patient is asked to cough several times. The resulting spikes in bladder and urethral pressures that occur are recorded, along with any urinary leakage. (Leakage that occurs immediately after the cough, is prolonged, is associated with an increase in true bladder pressure, or is of large volume suggests detrusor instability.)

If leak point pressures are to be measured, the volume of the bladder must be adjusted to 200 mL, and the pressure catheter must be no greater than 10 French. The true detrusor pressure is calculated by the subtraction of the reference pressure (from the vagina or rectum) from the pressures recorded from the urethra and bladder. The urodynamics equipment itself generally does this subtraction automatically. The patient is asked to strain, and the pressure at which leakage occurs (if any) is noted.

Pressure measurements conclude with the reference pressure catheter being removed and urethral profilometry being performed. This is accomplished using the machine’s catheter puller to remove the bladder catheter at a known rate while continuous pressures are recorded. Pressure profiles are thus compiled by the urodynamics equipment; this may be repeated while the patient coughs to obtain a dynamic profile.

Cystoscopy is commonly performed as a part of complex urodynamics testing and is carried out at this point in the testing process.

Uroflowmetry is carried out using the urodynamic equipment’s commode, which is equipped to measure flow rate, volume, and time. These are automatically recorded and displayed in formats that are determined by the specific equipment.

Cystometrics are associated with a false-negative rate of approximately 50% and a false-positive rate of 15% in cases of urge incontinence.

COMPLICATIONS

Urinary tract infection, dysuria, urinary retention.

FOLLOW-UP

Based on indications and findings.

CPT CODE(S)

51726 Complex urodynamics

51772 Urethral profilometry

51741 Complex uroflowmetry

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