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Traces: making sense of urodynamics testing--part 12: videourodynamics testing.

Videourodynamics testing combines radiographic images of the lower urinary tract with physiologic tracings from multichannel urodynamics testing to provide a more comprehensive evaluation of lower urinary function than either modality completed alone. Part 12 of the Traces series describes the role of videourodynamics testing in evaluation of the lower urinary tract and its unique contribution to the diagnosis of specific lower urinary tract disorders.

Traces: making sense of urodynamics testing--Part 11: quantitative analysis of micturition via the voiding pressure flow study: pressure-flow nomograms.

The voiding pressure flow study is the gold standard for evaluating micturition. Part 10 of the Traces series described techniques for evaluating micturition via the voiding pressure flow study; it focused on interpretation of results qualitatively via inspection and classification of flow pattern, detrusor contraction amplitude and duration, pelvic floor muscle response to voiding, and urethral resistance. This article discusses quantitative analysis of the voiding pressure flow study using nomograms that measure the magnitude of urethral resistance (bladder outflow obstruction) and/or detrusor contraction strength.

Traces: making sense of urodynamics testing--Part 10: evaluation of micturition via the voiding pressure-flow study.

Part 10 of the Traces series focuses on urodynamics evaluation of micturition via the voiding pressure-flow study (VPS). This article reviews techniques for generating a high-quality voiding pressure-flow study and initial interpretation of findings. Part 11 of the Traces series will focus on advanced analysis of the VPS using nomograms that measure the magnitude of urethral resistance (bladder outflow obstruction) and detrusor contraction strength.

Traces: making sense of urodynamics testing--Part 9: Evaluation of sensations detrusor response to bladder filling.

Part 9 of the Traces series continues the discussion of how urodynamic clinicians generate usable data from a filling cystometrogram. This article focuses on the question: "What is the detrusor's response to bladder filling?" Answering this question requires the clinician to identify and differentiate detrusor contractions from abdominal events, artifacts, or low bladder wall compliance; documentation of the volume of the contraction; and assessment of its clinical relevance as an overactive or subclinical detrusor contraction.

Traces: making sense of urodynamics testing--part 7: Evaluation of bladder filling/storage: Evaluation of urethral sphincter incompetence and stress urinary incontinence.

The "Traces" series discusses how the urodynamic clinician generates usable data from a filling cystometrogram. Part 7 focuses on the question, "Is the urethral sphincter mechanism competent?" From a practical viewpoint, this question can be divided into two queries: 1) does this patient have observable urodynamic stress urinary incontinence (SUI), and 2) does this patient have intrinsic urethral sphincter incompetence, also referred to as intrinsic sphincter deficiency or a low pressure urethra? Signs of SUI include clinician observation of urine loss with coughing or during Valsalva's maneuver. Urodynamic SUI is the observation of urine loss with increased abdominal and intravesical pressures in the absence of a detrusor contraction. The most commonly used techniques for assessment of urethral sphincter function and SUI are the urethral pressure profile and the abdominal leak point pressure. Both are useful for answering these queries, but both tests are vulnerable to physiologic and technical artifacts that must be minimized to produce technically accurate and clinically meaningful results.

Traces: making sense of urodynamics testing--Part 6: Evaluation of bladder filling/ storage: bladder wall compliance and the detrusor leak point pressure.

This article defines the concept of bladder wall compliance, discusses various means of measuring or assessing compliance, and reviews its clinical relevance. Based on existing evidence, low bladder wall compliance is attributable to increased detrusor muscle tone during bladder filling or changes in the viscoelastic properties of the bladder wall that impede the bladder wall's ability to stretch. While one can identify the individual components that compromise compliance, the filling CMG is only able to detect whole bladder wall compliance (for example, the combined effects of increased detrusor muscle tone and compromised viscoelastic properties of the bladder wall). From a clinical perspective, whole bladder wall compliance is divided into two categories: normal and low. Low bladder wall compliance is clinically relevant because of its potential to produce upper urinary tract distress, and there is increased risk for febrile urinary tract infections, ureterohydronephrosis, vesicoureteral reflux, renal scarring, compromised urinary tract function, and urinary incontinence because of its direct influence on the bladder outlet. It may produce pain and pressure in the patient with preserved sensations of bladder filling. Low bladder wall compliance is associated with a variety of clinically relevant disorders, including neurogenic bladder dysfunction, pelvic irradiation, interstitial cystitis, and radical prostatectomy.

Traces: making sense of urodynamics testing--Part 5: evaluation of bladder filling/storage functions.

Lower urinary tract function is characterized by two stages: bladder filling/ storage and micturition. Natural bladder filling tends to be slow, intermittent, and variable, while urodynamics testing employs a continuous, supraphysiologic fill rate. A clear understanding of the typical proportion between bladder storage and micturition is essential when urodynamics findings are interpreted within a clinical setting. When completing a filling cystometrogram, the urodynamics clinician must answer five essential questions to generate clinical meaningful results: bladder capacity, bladder wall compliance, competence of the urethral sphincter mechanism, sensations of bladder filling, and detrusor response to bladder filling/storage. While the emphasis of each question differs depending on the patient's lower urinary tract symptoms and specific questions posed by the referring physician, the combined answers to these questions form a comprehensive evaluation of lower urinary tract filling and storage functions. This article will address how the urodynamic clinician answers the first question, "What is the capacity of this bladder?"

Anatomy and physiology of urinary elimination. Part 1.

Elimination of urine is an essential bodily function, but independence in this activity may be affected by physical and mental disability. Part 1 of this article discusses the anatomy and physiology of the renal and urinary tract and the production of urine. Urinalysis is a vital nursing assessment and the collection of specimens and the range of tests undertaken are outlined. Assisting patients to use the toilet, commode or bedpan is an essential nursing skill. The importance of sensitivity, empathy and moving and handling risk assessment is discussed, and the assessment and management of urinary tract infection and urinary tract stones are addressed. The importance of prevention of cross infection for nurses and patients is highlighted throughout the article.

Innovation in bladder assessment: use of technology in extended care.

Nursing homes are required to conduct a comprehensive assessment and screening of residents with urinary incontinence (UI) and indwelling catheter upon admission, and if there is a change in cognition, physical ability, or urinary tract function (Centers for Medicare and Medicaid Services [CMS], 2005). The desired goal is to improve the quality of care through the maintenance and the restoration of bladder function. CMS regulations and revised Tag F315 mandate that long-term care facilities appropriately assess and treat the specific bladder disorder of UI and decrease the inappropriate use of indwelling urinary catheters. Assessment includes evaluation for reversible factors that may cause UI, such as urinary retention and urinary tract infection. The scope of this article is to demonstrate the relationship between these bladder disorders and assessments that can be performed by nursing staff. Because invasive instrumentation of the bladder can increase the likelihood of urinary tract infections, the use of non-invasive technology that ensures quality and evidence-based clinical practice, while preventing associated medical problems in vulnerable residents, is necessary for bladder assessment in the extended care setting. With this technology, assessment of bladder function is easy for staff and provides information that can be vital to successful nursing care outcomes. The staff of CRISTA Senior Community changed clinical practice through incorporation of technology to determine the presence of bladder dysfunction. Staff accurately and effectively applied ultrasonography to determine the bladder volume and abnormalities with bladder emptying, with ultimate improvement in resident care. Adoption of technology can preserve the resident's dignity and respect, while ensuring the highest level of bladder function.