Normal voiding

Principles of pressure and pressure-flow analysis are identical to conventional cystometry. However additional findings may be recorded:

• Bladder—initial residual volume, shape and position, trabecu-lation, diverticula, ureteric reflux, fistula, and post-void residual

• Bladder neck—shape, descent of during stress or voiding

• Urethra—"milking back" on voluntary inhibition of voiding, stenosis, diverticula

• Demonstration of leakage

During filling, the bladder neck and urethra should remain closed. In some older women, the bladder neck may open on coughing or valsalva. On voiding, the bladder base may exhibit minimal descent, the bladder neck opens widely and normal voiding occurs through a relaxed and patent urethra. The bladder should empty to completion.

Stopping the urine flow voluntarily, results in contractions of the pelvic floor which "milk back" the urine into the bladder and the bladder neck closes.

Common abnormalities on VUDS

1. Incompetent bladder neck

• Bladder neck opening during filling or on coughing is abnormal in men and younger women. This may be due to involuntary detrusor contractions or bladder neck incompetence

2. Failure of bladder neck opening

• May be due to bladder neck stenosis, detrusor-sphincter dyssynergia, or a hypotonic bladder

• In the hypotonic bladder, pressure studies will confirm a low Pdet during voiding

• Higher voiding bladder pressures are noted with bladder neck stenosis and detrusor-sphincter dyssynergia

3. Stress incontinence

• Stress leakage may occur secondary to either urethral/ bladder neck hypermobility or intrinsic sphincter deficiency, or a combination of both

• Descent of the bladder neck is easily demonstrated on VUDS and can be graded (see below)

• In patients with significant intrinsic sphincter deficiency, there is minimal bladder neck descent on straining and prolonged leakage through an open urethra is the typical finding

• Blaivas and Olsson have proposed a classification system for genuine stress incontinence (GSI) based on the VUDS conclusions

Type 0—history of GSI but no leakage demonstrated on VUDS (possibly due to voluntary sphincteric contractions)

Type I—at rest the closed bladder neck is situated at or above the inferior margin of the symphysis pubis. On coughing there is demonstrable leakage. The bladder neck and proximal urethra open, but bladder neck descent is <2 cm

Type IIA—as above, except descent on coughing is >2 cm and there is an obvious cystourethrocoele

Type IIB—bladder neck closed at rest but lies below inferior margin of symphysis pubis. On coughing, leakage occurs with or without bladder neck descent

Type III—abnormally open bladder neck and proximal urethra during bladder filling

4. Ureteric reflux

• Seen during voiding

• May be unilateral or bilateral

• Often associated with a neurogenic bladder

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