Role of videourodynamic study in precision diagnosis and treatment for lower urinary tract dysfunction

Abstract

Lower urinary tract symptoms (LUTS) are complicated and cannot be used alone to diagnose lower urinary tract dysfunctions (LUTDs) and guide treatment. Patients with bladder outlet obstruction (BOO), impaired detrusor contractility, and hypersensitive bladder might present with voiding predominant symptoms, whereas patients with detrusor overactivity (DO), dysfunctional voiding, or BOO might also present with storage symptoms. To clearly identify the pathophysiology of LUTD, a comprehensive urodynamic study (UDS) including pressure flow and image during the storage and emptying phases, naming videourodynamic study (VUDS), is necessary. This study is especially mandatory in the diagnosis of (1) male LUTS refractory to medical treatment for benign prostatic hyperplasia, (2) female voiding dysfunction and urinary retention, (3) diagnosis of overactive bladder syndrome refractory to first-line medication, (4) management of female stress urinary incontinence and postoperative LUTS, (5) diagnosis and management of neurogenic LUTD, (6) pediatric urinary incontinence and enuresis, (7) geriatric urinary incontinence, and (8) recurrent bacterial cystitis. Although VUDS should not be used as a screening test for any LUTS, it should be considered when the initial management cannot relieve LUTS, or when invasive surgical procedure is planning to undertake for patients with refractory LUTS. VUDS should be recommended as the second-line investigation when the initial diagnosis and treatment based on the symptoms alone or noninvasive tests fail to improve LUTS.

Keywords: Diagnosis; Lower urinary tract symptoms; Treatment; Urodynamics.

Figure 1

The videourodynamic study findings in men with lower urinary tract symptoms: (a) benign prostatic obstruction and high-pressure bladder outlet obstruction, (b) primary bladder neck obstruction and high-pressure bladder outlet obstruction, (c) bladder neck dysfunction and low-pressure bladder outlet obstruction, (d) poor relaxation of external sphincter without bladder outlet obstruction

Figure 2

The detrusor overactivity occurs: (a) spontaneously during the end of bladder filling phase and spontaneous urination, and (b) provoked during coughs while urine leaks into the proximal urethra

Figure 3

The patients with voiding dysfunction after suburethral sling operation might be due to (a) poor relaxation of the pelvic floor muscles, (b) after medical treatment patient regained normal voiding, or (c) bladder outlet obstruction by the suburethral sling, (d) after release of the sling tension, the patient regained spontaneous voiding without difficulty

Figure 4

Videourodynamic study for spinal cord injured patients. (a) Contracted bladder with high-grade left vesicoureteral reflux and intrinsic sphincter deficiency in a patient with cervical spinal cord injury, (b) detrusor overactivity with external sphincter dyssynergia and open bladder neck. The vesicoureteral dysfunction found in videourodynamic study can guide correct treatment

Figure 5

Videourodynamic study for pediatric urinary incontinence in (a) a child with myelomeningocele and recurrent acute pyelonephrosis, the study demonstrated contracted bladder with detrusor sphincter dyssynergia and high-grade right vesicoureteral reflux, and (b) a child with cerebral palsy with recurrent urinary tract infection, the study showed bilateral high-grade reflux, which caused incorrect measurement of the safe functional bladder capacity for clean intermittent catheterization

Figure 6

Videourodynamic study of geriatric urinary incontinence in: (a) a patient with Parkinson’s disease and lower urinary tract symptoms refractory to alpha-blocker therapy, videourodynamic study revealed narrow bladder neck and poor relaxation of the external sphincter during voiding; (b) a patient with chronic stroke and urgency urinary incontinence, videourodynamic study revealed dysfunctional voiding at the spontaneous detrusor overactivity, normal detrusor pressure, and high maximum flow rate are noted at voiding. The voiding symptoms in these two patients are not related with prostatic hyperplasia and surgery is not necessary