Interpretation of Urodynamic Studies

Seung-June Oh

Interpretation of Urodynamic Studies

A Case Study-Based Guide

Korean edition was already in discussion with Korean publisher and author wishes the rights for Korean edition to be excluded. It was confirmed that Springer edition should be published before Korean edition.

ISBN 978-981-10-2283-8 ISBN 978-981-10-2284-5 (eBook)https://doi.org/10.1007/978-981-10-2284-5

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Seung-June Oh, M.D.Department of UrologySeoul National University HospitalSeoulSouth Korea

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To the Seoul National University Hospital that has always encouraged me to reach beyond the boundaries; to my mentor Professor Edward J. McGuire; and to my loving family.

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My friend Professor Oh asked me to write this as a Preface to his 900-page book on urodynamic theory and practice. Dr. Oh worked with me as a Fellow in Ann Arbor, Michigan, for 2 years. He is a hard-working, brilliant urologist who obtained a grant from the Paralyzed Veterans of America allowing him to videotape a large number of operations and urodynamics that I performed while he was with us. These included procedures which were novel but nev-ertheless worked to preserve the health and welfare of our patients.

Bladder, ureteral, and renal function are interconnected and urologists have tried to figure out how to define conditions which impair continence, renal function, and ureteral function as long as I can remember. When I started in urology in the early 70s, urologic care of patients with spinal cord injuries, multiple sclerosis, and strokes was reactive and not very successful. Prolonged catheter drainage killed bladders and led to a high pressure system, which impaired ureteral function and renal function.

The last resort treatment was a urinary diversion, which only led to more trouble. Sometime in the mid-70s, I refused to do ileal loop diversions as the long-term outcome of that procedure was very poor. I realized that the urinary tract could not survive high pressures generated by the neurogenic bladder, or with time the ileal loop, which became rigid and aperistaltic obstructing urine flow. To save the bladder, I sought ways to facilitate intermittent catheteriza-tion by the patient or in cases where that was not possible by a caregiver. We knew from our research in primates with created spinal cord injuries that bladder pressure controlled ureteral function. Detrusor pressures in excess of 40 cmH2O impaired ureteral delivery of urine to the bladder and if the bladder pressure was sustained at 40 cmH2O or more glomerular function ceased, a fact we determined with micropuncture studies, in the primates. For a time I was chastised by urologists working in my field for not using chronic indwell-ing catheters, as well as by rehabilitation doctors who loved suprapubic tubes (which they changed once monthly). Chronic catheter indwelling causes bladder fibrosis, impairs ureteral function, and once that happens, there is little one could do to save these patients from a slow death. In end stage cir-cumstances, I would make a neobladder from cecum and create a catheteriz-able stoma out of the appendix or from small bowel. Cecal loops have very low pressures, and those patients who had that done did very well indeed—even to this day. If I could not use the cecum, I made a segment of ileum into a bladder augmentation and created a continent catheterizable stoma from appendix if present or from another short ileal segment.

Foreword

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This rather confused field needed some serious work to develop urody-namic tests, which had prognostic value, so that interventions could be ratio-nally planned and implemented.

Professor Oh has exactly accomplished that with this book. He chose a case-based format, which is the way I learned urodynamics, doing them myself. He describes every useful urodynamic test. He presents the 5 and 6 channel pressure data and includes video images taken during the study. He presents the Abrams-Griffiths pressure flow studies which the Europeans use to diagnose prostatic obstruction, and he includes the graphic data so I assume he did these himself. He describes cystometric studies, flow rate determina-tions, cystoscopy with photographs, of the bladder and urethra, bladder tra-beculation, and bladder diverticula. There is a detailed discussion on stress incontinence, which covers leak point pressure testing.

In the beginning of the book, there is an easy to read and understand sec-tion on neurophysiology, with diagrams, which explains the autonomic inner-vation of the bladder, and the pontine and suprapontine centers which control it, and the parasympathetic and sympathetic systems which work together to facilitate micturition or coordinate bladder contraction and urethral relax-ation, and thus low pressure voiding.

The case-based material is very well organized and virtually every condi-tion which affects the urinary tract is described. Each case begins with a brief summary of the patient’s problems followed by the graphic pressure data, and usually video images from the study. I have done some 20,000 video urody-namic studies, which we kept on discs. I cannot imagine how Professor Oh put all of these into case studies with such clarity.

The entire range of urologic conditions is covered in detail in this book, including things that disturb the urodynamic study as pseudo-DSD, which looks like true DSD but is not. In addition, there is a small list of things which sometimes confuses the urodynamic diagnosis; Dr. Oh covers those as well. Toward the end of the book, Dr. Oh goes into more detail about selected cases whose urodynamic studies are depicted in the early chapters of the book, so that some idea of the outcome in these selected patients can be gathered.

In short, this is a really extraordinary book which covers every facet of urodynamics. I enjoyed reading it, so much so I went to bed reading it. It is a masterpiece.

Edward J. McGuire, M.D. Emeritus Professor of Urology

University of Michigan Ann Arbor, MI, USA

Retired in Florida

Foreword

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Lower urinary tract symptoms (LUTS) are the most commonly encountered problems in urology outpatients. In treating the patients with lower urinary tract symptoms, it is essential and important for urologists to acquire ade-quate knowledge in micturition physiology. Basic knowledge in the related fields such as neuroanatomy, neurophysiology, and neuropharmacology is also required. Most of all, urologists must possess a wide scope of knowledge in diagnostic methods for the assessment of lower urinary tract symptoms. Among such diagnostic methods, urodynamic study (UDS) is probably the most important tool. With proper applications of UDS, the diagnostic accu-racy can be greatly enhanced, and the treatment plan can be more elaborately refined.

Working at a tertiary hospital, the author receives many referrals of patients with complicated LUTS. Among these patients, those with prob-lems overlapping with other specialties are especially common. As well, some of the referred patients could have received more appropriate treat-ment had there been a better understanding of micturition and LUTS by healthcare professionals. Being rather concerned with this, the author has spent much time deliberating about the pathophysiology and treatment strat-egies in such cases.

In general, residents recognize lower urinary tract dysfunction as a consid-erably difficult topic; therefore, it is difficult for them to be interested in this area. Furthermore, as most of the daily healthcare services of urology focus on surgical procedures, the author is well aware that it is difficult to build solid knowledge on lower urinary tract dysfunction alone. For this reason, the author established an annual full-day course of “Intensive Course on UDS Interpretation for Seoul National University Hospital (SNUH) Residents and Practitioners” and has been running it since 2008. After running the course for a couple of years and contemplating about UDS education for residents, the author has reached the conclusion that there is a need for handy, readily applicable learning resource with easy-to-understand pictures and diagrams, instead of a massive textbook covering complicated theories.

SNUH carries out more than 1200 cases of UDS annually. The cases pre-sented in this book are selected from about 1300 cases seen in urology outpa-tient clinics, cystourethroscopy procedures, and consults from other specialties, collected for over the last 16 years since September 2000. The

Preface

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first half of the book introduces basic concepts and knowledge on the lower urinary tract function and UDS as well as basic UDS interpretation skills, and the second half covers various diseases that can cause LUTS. From the begin-ning, it was the author’s aim to write a book in a straightforward manner such that it is even comprehensible by medical students who are not very familiar with UDS. Thus, the author is convinced that this book will be also useful for technicians and nurses working in the field.

One thing that must be emphasized and made clear is that UDS is not the only all-round tool for the assessment of the LUTS of a patient. Obtaining the first clues from history and physical examination should always be a priority. Only when such clinical clues have been collected and analyzed can UDS help fill in further information that could not be acquired. Radiologic and laboratory findings may also be required for final diagnosis. Therefore, each case in this book contains not just UDS data but also history, physical examination, additional radiologic findings, and cystourethroscopic findings in order to help understand the disease and pathophysiology as a whole.

The author would like to thank Mr. Kwi-Shik Kim, Ms. Sang-A Byun, and Ms. So-Hee Shin of the Urodynamic Suite, Ms. Sung-Hwa Kim in the Clean Intermittent Catheterization Center of the SNUH, and Ms. Ji-Young Won for collecting and organizing the materials for the book. The author would also like to thank Jay Hoon Park, Dong Myeong Kim, Jo Hyung Dong, and Hyuk Jun Lee, medical students of Seoul National University, and Jason Jung, a medical student of the University of Sydney, for their dedication in the trans-lation or review of the manuscript or illustration of the diagrams. The author specially thanks Mr. Jan-Willem van der Wal for his kindness in providing technical support on the urodynamic machine. Last but not least, the author would also like to thank Professor Edward J. McGuire for generously sharing his knowledge and experience during the author’s 2-year fellowship at the University of Michigan Hospital and Professor Craig V. Comiter of Stanford University for his consultation and strong encouragement upon making the decision to write this book.

Book Features• Basically, this book is a case-based illustration. Each case was described

as simply as possible. Take-home lessons are presented for each case.• This book does not contain too many theoretical details and, instead, pur-

sued a practical approach to understanding of the urodynamic study.• The cases presented in this book are from large urodynamic study archives

in SNUH.• In addition to urodynamic traces, this book contains additional related

information such as frequency-volume charts, imaging studies, cystoure-throscopy, etc. for comprehensive understanding.

• This book reflects the most updated terminology published by the International Continence Society in 2017 and 2018.

Preface

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Disclaimer• In assessing patients’ symptoms, International Prostate Symptom Score

(IPSS) was applied across the cases and was described in the main text. As is well known, IPSS is a questionnaire used for aged men with benign prostate hyperplasia. There is little to no evidence supporting the validity of applying IPSS to neurogenic bladder or female lower urinary tract dys-function. The author hopes the readers to refer to the symptom severity of the LUTS for just a rough estimate.

• Urodynamic study was conducted using the device from Solar Medical Measurement Systems (Enschede, the Netherlands). The result was recorded using MMS Database Software (ver 8.21d, Medical Measurement Systems B. V., the Netherlands).

• There is no absolute solution to treat lower urinary tract dysfunction in most cases. The author has endeavored to provide the most reasonable and objective description based on his knowledge and experience. Nonetheless, experts may come up with different conclusions for some of the cases presented in this book.

• In real clinical practice settings, differences in the practice environment are inevitable. Therefore, some of the descriptions provided in this text-book may not represent the actual clinical practice armamentarium or policy of the readers. Thus, the contents of the book are recommended just as a guide.

Seoul, South Korea Seung-June Oh, M.D.

Preface

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Contents

Part I Ten-Minute Neurophysiology and Overview of Urodynamic Study

1 Ten-Minute Neurophysiology � � � � � � � � � � � � � � � � � � � � � � � � � � � � 3 1.1 Step 1: Urinary Bladder/Urethral Sphincter . . . . . . . . . . . . . . 3 1.2 Step 2: Overview of Micturition Center and Nuclei

Related to Storage and Voiding . . . . . . . . . . . . . . . . . . . . . . . . 4 1.3 Step 3: Bladder/Sphincter . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.4 Step 4: Bladder/Sphincter and Pontine Micturition Center . . . . 5 1.5 Step 5: Bladder/Sphincter, Pontine Micturition

Center and Cerebral Cortex . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.6 Local Reflex Circuits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.7 Storage Phase Mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.8 Voiding Phase Mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.9 Pathologic Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.10 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2 Overview of Urodynamic Study � � � � � � � � � � � � � � � � � � � � � � � � � � 13 2.1 Turning Pressure and Flow into a Signal . . . . . . . . . . . . . . . . . 14 2.2 Step 1: Pves Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.3 Step 2: Pves and Pabd Measurement . . . . . . . . . . . . . . . . . . . . 16 2.4 Step 3: Pves Measurement, Pabd

Measurement and Electromyography . . . . . . . . . . . . . . . . . . . 17 2.5 Step 4: Pves Measurement, Pabd Measurement,

Electromyography and Uroflowmetry . . . . . . . . . . . . . . . . . . . 18 2.6 Step 5: Pves Measurement, Pabd Measurement,

Electromyography, Uroflowmetry and Filling Device . . . . . . . 19 2.7 Step 6: Pves Measurement, Pabd Measurement,

Electromyography, Uroflowmetry, Filling Device and Fluoroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

2.8 Role of Urodynamic Study in Lower Urinary Tract Dysfunction . . . 21 2.9 Considerations Before Urodynamic Study: Patient Perspectives . . . 22References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

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Part II Diagnostic Process and Normal Findings of Urodynamic Study

3 Diagnostic Process � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 27 3.1 History Taking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

3.1.1 History Taking of LUTS and Related Points . . . . . . . . 27 3.1.2 Case Example. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

3.2 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 3.3 Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

3.3.1 Focused Neurological Examination . . . . . . . . . . . . . . . 31 3.4 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 3.5 Blood and Urine Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 3.6 Imaging Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

3.6.1 Simple X-ray: KUB . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 3.6.2 Intravenous Pyelography . . . . . . . . . . . . . . . . . . . . . . . 36 3.6.3 Retrograde Urethrography . . . . . . . . . . . . . . . . . . . . . . 37 3.6.4 Retrograde Urethrography: Urethral Stricture . . . . . . . 37 3.6.5 Voiding Cystourethrography: Normal . . . . . . . . . . . . . 38 3.6.6 CT: No Hydronephrosis . . . . . . . . . . . . . . . . . . . . . . . . 39 3.6.7 Ultrasonography: No Hydronephrosis . . . . . . . . . . . . . 39 3.6.8 CT: Hydronephrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 3.6.9 CT: Acute Pyelonephritis . . . . . . . . . . . . . . . . . . . . . . . 40 3.6.10 CT: Normal Urinary Bladder . . . . . . . . . . . . . . . . . . . . 41 3.6.11 CT: Bladder Trabeculation . . . . . . . . . . . . . . . . . . . . . . 41 3.6.12 CT: Bladder Wall Thickening . . . . . . . . . . . . . . . . . . . 42 3.6.13 Ultrasonography: Bladder Wall Thickening . . . . . . . . 42 3.6.14 CT: Bladder Stone . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 3.6.15 CT: Surrounding Structures (Prostate) . . . . . . . . . . . . . 43 3.6.16 CT: Fecal Impaction . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 3.6.17 Significance of Upper Tract Imaging . . . . . . . . . . . . . . 44

3.7 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 3.7.1 Cystourethroscopy in Normal Male . . . . . . . . . . . . . . . 46 3.7.2 Cystourethroscopy in Normal Female . . . . . . . . . . . . . 47 3.7.3 Cystourethroscopy: Urethral Stricture . . . . . . . . . . . . . 48 3.7.4 Cystourethroscopy: Incompetent Bladder Neck . . . . . 48 3.7.5 Cystourethroscopy: Bladder Neck

in Post-prostatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . 49 3.7.6 Cystourethroscopy: Enlarged Prostate . . . . . . . . . . . . . 49 3.7.7 Cystourethroscopy: Bladder Neck Configuration . . . . 50 3.7.8 Cystourethroscopy: Bladder Trabeculation . . . . . . . . . 51 3.7.9 Cystourethroscopy: Bladder Diverticulum . . . . . . . . . 52 3.7.10 Cystourethroscopy: Bladder Stone . . . . . . . . . . . . . . . 52

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

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4 Normal Findings of Urodynamic Study � � � � � � � � � � � � � � � � � � � 55 4.1 Uroflowmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

4.1.1 Uroflowmetry Showing Bell-Shaped Normal Voiding Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

4.1.2 Flow-EMG Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 4.1.3 Flow-EMG Study Showing Normal Synergic . . . . . . . 58

4.2 Measurement of Postvoid Residual Volume . . . . . . . . . . . . . . 59 4.2.1 Portable Ultrasound Equipment

for Measuring PVR . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 4.2.2 Abnormal Postvoid Residual Volume . . . . . . . . . . . . . 60 4.2.3 Overestimation of Postvoid Residual Volume . . . . . . . 61

4.3 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 4.3.1 Parameters of Urethral Pressure Profile . . . . . . . . . . . . 63 4.3.2 Urethral Pressure Profile: Clinical Significance . . . . . 63 4.3.3 Urethral Pressure Profile in Normal Male . . . . . . . . . . 64 4.3.4 Urethral Pressure Profile in Normal Female . . . . . . . . 65 4.3.5 Urethral Pressure Profile in Enlarged Prostate . . . . . . . 66 4.3.6 Urethral Pressure Profile in Incompetent Urethra . . . . 67

4.4 Pelvic Muscle Electromyography . . . . . . . . . . . . . . . . . . . . . . 68 4.4.1 EMG: Clinical Significance . . . . . . . . . . . . . . . . . . . . . 68 4.4.2 Normal EMG During Filling Phase . . . . . . . . . . . . . . . 69 4.4.3 Normal EMG During Voiding Phase . . . . . . . . . . . . . . 70 4.4.4 EMG Showing Detrusor Sphincter Dyssnergia . . . . . . 71

4.5 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 4.5.1 Measurement Principle of Filling Cystometry . . . . . . 72 4.5.2 Normal Filling Cystometry in Upright Position . . . . . 73 4.5.3 Normal Filling Cystometry in Supine Position . . . . . . 74

4.6 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 4.6.1 Pressure-Flow Study in a Normal Male . . . . . . . . . . . . 76 4.6.2 Pressure-Flow Study in a Normal Female . . . . . . . . . . 77

4.7 Urodynamic Stress Test: Abdominal Leak Point Pressure . . . . 78 4.7.1 Abdominal Leak Point Pressure in the Female

Stress Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . 79 4.7.2 Abdominal Leak Point Pressure in Male Post-

prostatectomy Stress Urinary Incontinence . . . . . . . . . 80 4.8 Detrusor Leak Point Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . 81

4.8.1 Definition of Detrusor Leak Point Pressure . . . . . . . . . 81 4.8.2 Detrusor Leak Point Pressure over

40 cmH2O (Case 1/2) . . . . . . . . . . . . . . . . . . . . . . . . . . 82 4.8.3 Detrusor Leak Point Pressure over

40 cmH2O (Case 2/2) . . . . . . . . . . . . . . . . . . . . . . . . . . 83

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4.9 Fluoroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 4.9.1 Normal Fluoroscopy of Bladder Neck

at Filling Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 4.9.2 Normal Fluoroscopy of Bladder Neck

at Voiding Phase in Male . . . . . . . . . . . . . . . . . . . . . . . 85 4.9.3 Normal Fluoroscopy of Bladder Neck

at Voiding Phase in Female . . . . . . . . . . . . . . . . . . . . . 86 4.10 Ambulatory Urodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

4.10.1 Usefulness of Ambulatory Urodynamics (Case 1/2) . . . 88 4.10.2 Usefulness of Ambulatory Urodynamics (Case 2/2) . . . 89

4.11 Integration of Clinical Information (Case 1/4) . . . . . . . . . . . . 90 4.12 Integration of Clinical Information (Case 2/4) . . . . . . . . . . . . 91 4.13 Integration of Clinical Information (Case 3/4) . . . . . . . . . . . . 92 4.14 Integration of Clinical Information (Case 4/4) . . . . . . . . . . . . 93 4.15 Importance of Urodynamic Follow-Up (Case 1/3) . . . . . . . . . 94 4.16 Importance of Urodynamic Follow-Up (Case 2/3) . . . . . . . . . 96 4.17 Importance of Urodynamic Follow-Up (Case 3/3) . . . . . . . . . 97References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Part III Basic UDS Interpretation Skill: Abnormal Findings

5 Abnormal Findings of Urodynamic Study During Storage Phase � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 101 5.1 ICS Classification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 5.2 Uroflowmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

5.2.1 Uroflowmetry Showing Tower-Shaped Superflow . . . 104 5.2.2 Uroflowmetry Showing Compressive Obstruction

(Benign Prostatic Obstruction) . . . . . . . . . . . . . . . . . . 105 5.2.3 Uroflowmetry Showing Plateau-Shaped

Constrictive Pattern (Urethral Stricture) . . . . . . . . . . . 106 5.2.4 Uroflowmetry Showing Interrupted-Shaped

(Abdominal Straining) . . . . . . . . . . . . . . . . . . . . . . . . . 107 5.2.5 Uroflowmetry Showing Intermittent Straining

Flow Pattern (Detrusor Underactivity) . . . . . . . . . . . . . 108 5.2.6 Uroflowmetry Showing Interrupted-Shaped

(Detrusor Sphincter Dyssynergia) . . . . . . . . . . . . . . . . 109 5.2.7 Uroflowmetry Showing Staccato-Shaped

(Dysfunctional Voiding) . . . . . . . . . . . . . . . . . . . . . . . . 110 5.2.8 Flow-EMG Showing Abdominal Straining . . . . . . . . . 111 5.2.9 Flow-EMG Showing Detrusor

Sphincter Dyssynergia . . . . . . . . . . . . . . . . . . . . . . . . . 112 5.3 Bladder Function During Storage Phase:

Involuntary Detrusor Contraction . . . . . . . . . . . . . . . . . . . . . . 113 5.3.1 Characteristic Shape of Detrusor Contraction . . . . . . . 114 5.3.2 Phasic Detrusor Overactivity . . . . . . . . . . . . . . . . . . . . 115 5.3.3 Terminal Detrusor Overactivity . . . . . . . . . . . . . . . . . . 116 5.3.4 Both Phasic and Terminal Detrusor Overactivity . . . . 117

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5.4 Bladder Function During Storage Phase: Bladder Sensation . . . 118 5.4.1 Bladder Oversensitivity . . . . . . . . . . . . . . . . . . . . . . . . 119 5.4.2 Reduced Bladder Sensation (Case 1) . . . . . . . . . . . . . . 120 5.4.3 Reduced Bladder Sensation (Case 2) . . . . . . . . . . . . . . 121 5.4.4 Absent Bladder Sensation . . . . . . . . . . . . . . . . . . . . . . 122 5.4.5 Bladder Sensation as Bladder Pain . . . . . . . . . . . . . . . 123 5.4.6 Nonspecific Bladder Awareness . . . . . . . . . . . . . . . . . . 124

5.5 Bladder Function During Storage Phase: Bladder Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 5.5.1 High Bladder Capacity . . . . . . . . . . . . . . . . . . . . . . . . . 127 5.5.2 Low Bladder Capacity (Case 1) . . . . . . . . . . . . . . . . . . 128 5.5.3 Low Bladder Capacity (Case 2) . . . . . . . . . . . . . . . . . . 129

5.6 Bladder Function During Storage Phase: Bladder Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 5.6.1 Normal Bladder Compliance . . . . . . . . . . . . . . . . . . . . 131 5.6.2 Low Bladder Compliance (Neurogenic) . . . . . . . . . . . 132 5.6.3 Reduced Bladder Compliance

(Neurogenic Bladder with Bladder Fibrosis) . . . . . . . . 133 5.6.4 Low Bladder Compliance (Non-neurogenic

Decompensation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 5.7 Urethral Function During Storage Phase:

Incompetent Urethral Closure Mechanism . . . . . . . . . . . . . . . 137 5.7.1 Incompetent Bladder Neck (Case 1/3):

Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . 138 5.7.2 Incompetent Bladder Neck (Case 2/3):

Abdominal Leak Point Pressure . . . . . . . . . . . . . . . . . 140 5.7.3 Incompetent Bladder Neck (Case 3/3):

Fluoroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 5.8 Urethral Function During Storage Phase:

Urodynamic Stress Urinary Incontinence . . . . . . . . . . . . . . . . 142 5.8.1 Urodynamic Stress Urinary Incontinence . . . . . . . . . . 142

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144

6 Abnormal Findings of Urodynamic Study During Voiding Phase � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 145 6.1 Bladder Function at Emptying:

Underactive/Acontractile Detrusor . . . . . . . . . . . . . . . . . . . . . 145 6.1.1 Underactive Detrusor with

Low Amplitude of Contraction . . . . . . . . . . . . . . . . . . 146 6.1.2 Underactive Detrusor with

Unsustained Contraction . . . . . . . . . . . . . . . . . . . . . . . 148 6.1.3 Acontractile Detrusor . . . . . . . . . . . . . . . . . . . . . . . . . . 150 6.1.4 Normal Bladder Function:

Special Consideration in Women . . . . . . . . . . . . . . . . . 152 6.1.5 Normal Detrusor Function: Special

Consideration in Men with Post-Prostatectomy Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

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6.2 Urethral Function During Voiding Phase: Mechanical Bladder Outflow Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . 156 6.2.1 Bladder Outflow Obstruction in Men . . . . . . . . . . . . . 156 6.2.2 Bladder Outflow Obstruction in Women . . . . . . . . . . . 156 6.2.3 Mechanical Bladder Outflow Obstruction: BPH . . . . . 157 6.2.4 Limitation: When There Is No Flow . . . . . . . . . . . . . . 159

6.3 Urethral Function During Voiding Phase: Detrusor Sphincter Dyssynergia . . . . . . . . . . . . . . . . . . . . . . . 160 6.3.1 Detrusor Sphincter Dyssynergia in Male . . . . . . . . . . . 161 6.3.2 Detrusor Sphincter Dyssynergia in Female . . . . . . . . . 163 6.3.3 Pseudo-DSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 6.3.4 Pseudo-DSD: Guarding Reflex (Case 1) . . . . . . . . . . . 166 6.3.5 Pseudo-DSD: Guarding Reflex (Case 2) . . . . . . . . . . . 168 6.3.6 Guarding Reflex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 6.3.7 Pseudo-DSD: Leg Tremor (Case 3) . . . . . . . . . . . . . . . 172 6.3.8 Concomitant Smooth Sphincter Dyssynergia . . . . . . . 174

6.4 Urethral Function During Voiding Phase: Dysfunctional Voiding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 6.4.1 Dysfunctional Voiding (Case 1/2) . . . . . . . . . . . . . . . . 177 6.4.2 Dysfunctional Voiding (Case 2/2) . . . . . . . . . . . . . . . . 178

6.5 Urethral Function During Voiding Phase: Non-relaxing Urethral Sphincter Obstruction . . . . . . . . . . . . . 180 6.5.1 Non-relaxing Urethral Sphincter

Obstruction (Case 1 1/2) . . . . . . . . . . . . . . . . . . . . . . . 181 6.5.2 Non-relaxing Urethral Sphincter

Obstruction (Case 1 2/2) . . . . . . . . . . . . . . . . . . . . . . . 183 6.6 Urethral Function During Voiding Phase:

Delayed Relaxation of the Urethral Sphincter (Case 1/2) . . . . 185 6.7 Urethral Function During Voiding Phase:

Delayed Relaxation of the Urethral Sphincter (Case 2/2) . . . . 186References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

7 Fluoroscopic Abnormalities � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 189 7.1 Fluoroscopic Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

7.1.1 Key Considerations in Video Urodynamics . . . . . . . . . 190 7.1.2 Importance of Scout Imaging (Case 1) . . . . . . . . . . . . 191 7.1.3 Importance of Scout Imaging (Case 2) . . . . . . . . . . . . 192 7.1.4 Importance of Scout imaging (Case 3) . . . . . . . . . . . . 193 7.1.5 Incompetent Bladder Neck in Filling Phase . . . . . . . . 194 7.1.6 Prostatic Enlargement Associated

with Vesicoureteral Reflux in Filling Phase . . . . . . . . . 195 7.1.7 Vesicoureteral Reflux in Filling Phase (Case 1) . . . . . 196 7.1.8 Vesicoureteral Reflux in Filling Phase (Case 2) . . . . . 197 7.1.9 Trabeculation in Filling Phase . . . . . . . . . . . . . . . . . . . 198 7.1.10 Bladder Trabeculation Grade . . . . . . . . . . . . . . . . . . . . 198 7.1.11 Hugh Bladder Diverticulum in Filling Phase . . . . . . . . 199 7.1.12 Bladder Saccule in Filling Phase . . . . . . . . . . . . . . . . . 200 7.1.13 Contracted Bladder with Bilateral

Vesicoureteral Reflux . . . . . . . . . . . . . . . . . . . . . . . . . 201 7.1.14 Vesicoureteral Reflux at Bladder

Contraction in Voiding Phase . . . . . . . . . . . . . . . . . . . . 202

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7.1.15 Voiding Phase: Intraprostatic Reflux . . . . . . . . . . . . . . 203 7.1.16 Male DSD in Voiding Phase . . . . . . . . . . . . . . . . . . . . 204 7.1.17 Female DSD in Voiding Phase . . . . . . . . . . . . . . . . . . 206 7.1.18 Localization of Obstruction in 

Male during Voiding Phase . . . . . . . . . . . . . . . . . . . . . 208 7.1.19 Primary Bladder Neck Obstruction

During Voiding Phase . . . . . . . . . . . . . . . . . . . . . . . . . 210 7.1.20 Large Amount of Postvoid Residual in

Postvoid View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 7.1.21 Detection of Leakage During Urodynamic

Stress Test in Female . . . . . . . . . . . . . . . . . . . . . . . . . . 213 7.1.22 Bladder Expression to Void in Female . . . . . . . . . . . . . 214 7.1.23 Detection of Leakage During

Urodynamic Stress Test in Male . . . . . . . . . . . . . . . . . 216 7.1.24 Detection of Urinary Leakage: Fistula . . . . . . . . . . . . . 217

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

Part IV Pitfalls and Artifacts in the UDS

8 Correction of Urodynamic Error � � � � � � � � � � � � � � � � � � � � � � � � 221 8.1 Situational Inability to Void As Usual . . . . . . . . . . . . . . . . . . . 221

8.1.1 “Situational Inability to Void As Usual” in Presumptive Neurogenic Bladder (Case 1 1/3) . . . . . . 222

8.1.2 “Situational Inability to Void As Usual” in Presumptive Neurogenic Bladder (Case 1 2/3) . . . . . . 223

8.1.3 “Situational Inability to Void As Usual” in Presumptive Neurogenic Bladder (Case 1 3/3) . . . . . . 224

8.1.4 “Situational Inability to Void As Usual” in Neurologically Normal Patient (Case 2) . . . . . . . . . . . 226

8.2 Uroflowmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 8.2.1 Uroflowmetry: Wag Artifact. . . . . . . . . . . . . . . . . . . . . 229 8.2.2 Uroflowmetry: Uneven Collection of Urine . . . . . . . . 230 8.2.3 Uroflowmetry: High Flow Obstruction . . . . . . . . . . . . 231 8.2.4 Uroflowmetry: Abdominal Straining . . . . . . . . . . . . . . 233 8.2.5 Uroflowmetry: Fecal Incontinence

During Uroflowmetry . . . . . . . . . . . . . . . . . . . . . . . . . . 234 8.2.6 Uroflowmetry: Artificial Noise Signals . . . . . . . . . . . . 235 8.2.7 Flow-EMG: Inconsistent EMG Findings . . . . . . . . . . . 236

8.3 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 8.3.1 Urethral Pressure Profile: Voluntary

Pelvic Floor Contraction . . . . . . . . . . . . . . . . . . . . . . . 240 8.3.2 Urethral Pressure Profile: Low Infusate Pressure . . . . 241 8.3.3 Urethral Pressure Profile:

Involuntary Detrusor Contraction . . . . . . . . . . . . . . . . 243 8.3.4 Urethral Pressure Profile:

Chronic Indwelling Urethral Catheter . . . . . . . . . . . . . 245 8.3.5 Urethral Pressure Profile:

Excessively Longer FPL (Case 1 1/2) . . . . . . . . . . . . . 247 8.3.6 Urethral Pressure Profile:

Excessively Longer FPL (Case 1 2/2) . . . . . . . . . . . . . 248

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8.4 Urodynamic Stress Test (Abdominal Leak Point Pressure) . . . . . . . . . . . . . . . . . . . . . . 249 8.4.1 Abdominal Leak Point Pressure:

Involuntary Detrusor Contraction . . . . . . . . . . . . . . . . 250 8.4.2 Abdominal Leak Point Pressure:

Expelled Pves Catheter . . . . . . . . . . . . . . . . . . . . . . . . 251 8.4.3 Abdominal Leak Point Pressure:

Dampening of Pabd . . . . . . . . . . . . . . . . . . . . . . . . . . . 252 8.4.4 Abdominal Leak Point Pressure:

Pabd Catheter Slippage into the Rectocele . . . . . . . . . 253 8.4.5 Abdominal Leak Point Pressure:

Pelvic Floor Laxity . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 8.4.6 Abdominal Leak Point Pressure:

Overestimation Due to Catheter Itself . . . . . . . . . . . . . 255 8.5 Detrusor Leak Point Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . 257

8.5.1 Detrusor Leak Point Pressure: Involuntary Detrusor Contraction . . . . . . . . . . . . . . . . 258

8.5.2 Detrusor Leak Point Pressure: Underestimation by Vesicoureteral Reflux . . . . . . . . . 259

8.6 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 8.6.1 Filling Cystometry: Initial Resting Pressure . . . . . . . . 262 8.6.2 Filling Cystometry: Air Bubble in the Pabd

Pressure Tubing System . . . . . . . . . . . . . . . . . . . . . . . . 263 8.6.3 Filling Cystometry: Repeat Filling . . . . . . . . . . . . . . . 264 8.6.4 Filling Cystometry: Position . . . . . . . . . . . . . . . . . . . . 266 8.6.5 Filling Cystometry: Filling Rate . . . . . . . . . . . . . . . . . 268 8.6.6 Filling Cystometry: Bowel Gas . . . . . . . . . . . . . . . . . . 270 8.6.7 Filling Cystometry: Rectal Contraction . . . . . . . . . . . . 272 8.6.8 Filling Cystometry: Small Rectal Contractions . . . . . . 273 8.6.9 Filling Cystometry: Synchronous Change in Pves

with Corresponding Rectal Contraction (Case 1) . . . . 274 8.6.10 Filling Cystometry: Synchronous Change in Pves

with Corresponding Rectal Contraction (Case 2) . . . . 276 8.6.11 Filling Cystometry: Synchronous Change in Pves

with Corresponding Rectal Contraction (Case 3) . . . . 278 8.6.12 Filling Cystometry: Detecting Involuntary Detrusor

Contraction Is Challenging in Pdet Trace . . . . . . . . . . 279 8.6.13 Filling Cystometry: Abdominal Breathing . . . . . . . . . 280 8.6.14 Filling Cystometry: Voluntary Pelvic Floor

Muscle Contraction . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 8.6.15 Filling Cystometry: Summation of

Involuntary Detrusor Contraction Rather Than Poor Bladder Compliance . . . . . . . . . . . . . . . . . . . . . . 283

8.6.16 Filling Cystometry: Poor Bladder Compliance . . . . . . 285

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8.6.17 Filling Cystometry: Underestimated Bladder Compliance. . . . . . . . . . . . . . . . . . . . . . . . . . . 286

8.6.18 Filling Cystometry: Correction of Filled Volume for Diuresis . . . . . . . . . . . 288

8.7 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 8.7.1 Pressure-Flow Study: Expelled Pves Catheter . . . . . . . 290 8.7.2 Pressure-Flow Study: Expelled Pves Catheter . . . . . . . 292 8.7.3 Pressure-Flow Study: Pves Catheter Hole Getting

Touched Against the Bladder Mucosal Surface . . . . . . 294 8.7.4 Pressure-Flow Study: Rectal Contraction . . . . . . . . . . 296 8.7.5 Pressure-Flow Study: Flatus . . . . . . . . . . . . . . . . . . . . 298 8.7.6 Pressure-Flow Study: Urge to Defecate . . . . . . . . . . . . 300 8.7.7 Pressure-Flow Study: Voluntary Pelvic

Floor Muscle Contraction (Case 1) . . . . . . . . . . . . . . . 302 8.7.8 Pressure-Flow Study: Voluntary Pelvic

Floor Muscle Contraction (Case 2) . . . . . . . . . . . . . . . 304 8.7.9 Pressure-Flow Study: Involuntary

Detrusor Contraction Before Permission to Void . . . . 306 8.7.10 Pressure-Flow Study: Dropped Pabd at Void . . . . . . . . 308 8.7.11 Pressure-Flow Study: After-Contraction . . . . . . . . . . . 309 8.7.12 Pressure-Flow Study: After-Contraction? . . . . . . . . . . 311 8.7.13 Pressure-Flow Study: Wag Artifact in Flow. . . . . . . . . 312 8.7.14 Pressure-Flow Study: Blockage by Blood Clot . . . . . . 314

8.8 Pelvic Muscle Electromyography . . . . . . . . . . . . . . . . . . . . . . 316 8.8.1 Pelvic Muscle EMG: Contact with Infusate . . . . . . . . 317 8.8.2 Pelvic Muscle EMG: ElectroMagnetic Interference . . . 318 8.8.3 Pelvic Muscle EMG: Weak Signal . . . . . . . . . . . . . . . . 320 8.8.4 Pelvic Muscle EMG: Urge to

Defecate During Filling Cystometry . . . . . . . . . . . . . . 322 8.8.5 Pelvic Muscle EMG:

Hiccup During Filling Cystometry . . . . . . . . . . . . . . . 323 8.8.6 Pelvic Muscle EMG:

Guarding Reflex Filling Cystometry . . . . . . . . . . . . . . 324 8.8.7 Pelvic Muscle EMG: Habitual

Contraction of Pelvic Floor Muscle Before Voiding. . . 325 8.8.8 Pelvic Muscle EMG: Lower Limb Weakness . . . . . . . 327 8.8.9 Pelvic Muscle EMG: Lower Limb Spasticity . . . . . . . 328

8.9 Fluoroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329 8.9.1 Fluoroscopy: Its Clinical Significance . . . . . . . . . . . . . 330 8.9.2 Fluoroscopy: Overlapping Symphysis

Pubis with Bladder Neck . . . . . . . . . . . . . . . . . . . . . . . 332 8.9.3 Fluoroscopy: Timing . . . . . . . . . . . . . . . . . . . . . . . . . . 333

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

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Part V Typical Patterns

9 Urological Diseases � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 339 9.1 A 62-Year-Old Male with Benign Prostatic Obstruction

Presenting with Acute Urinary Retention . . . . . . . . . . . . . . . . 339 9.1.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340 9.1.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . . 341 9.1.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . . 342 9.1.4 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . 343 9.1.5 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344 9.1.6 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . . 345 9.1.7 Summary of Urodynamic Findings . . . . . . . . . . . . . . . 346 9.1.8 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . . 346 9.1.9 Transrectal Ultrasonography of Prostate . . . . . . . . . . . 346 9.1.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 9.1.11 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . . 347 9.1.12 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . 347

9.2 A 68-Year-Old Male with Benign Prostatic Obstruction and Detrusor Overactivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348 9.2.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348 9.2.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . . 349 9.2.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . . 350 9.2.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 9.2.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . . 352 9.2.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . 353 9.2.7 Summary of Urodynamic Findings . . . . . . . . . . . . . . . 354 9.2.8 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . . 354 9.2.9 Transrectal Ultrasonography of Prostate . . . . . . . . . . . 354 9.2.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355 9.2.11 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . . 355 9.2.12 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . 355

9.3 A 39-Year-Old Male with Bladder Neck Dysfunction on Clean Intermittent Catheterization . . . . . . . . . 356 9.3.1 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . . 356 9.3.2 Filling and Pressure-Flow Study . . . . . . . . . . . . . . . . . 357 9.3.3 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . . 358 9.3.4 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . 359 9.3.5 Summary of Urodynamic Findings . . . . . . . . . . . . . . . 360 9.3.6 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . . 360 9.3.7 Transrectal Ultrasonography of Prostate . . . . . . . . . . . 360 9.3.8 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361 9.3.9 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361 9.3.10 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . . 362 9.3.11 Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362 9.3.12 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . 362

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9.4 A 53-Year-Old Male with High Flow Obstruction Presenting with Voiding Difficulty. . . . . . . . . . . . 363 9.4.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363 9.4.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . . 364 9.4.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . . 365 9.4.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366 9.4.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . . 367 9.4.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . 368 9.4.7 Summary of Urodynamic Findings . . . . . . . . . . . . . . . 369 9.4.8 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . . 369 9.4.9 Transrectal Ultrasonography of Prostate . . . . . . . . . . . 369 9.4.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370 9.4.11 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . . 370 9.4.12 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . 370

9.5 A 50-Year-Old Male with Bladder Outflow Obstruction Presenting with Voiding Difficulty . . . . . . . . . . . . . . . . . . . . . 371 9.5.1 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . . 371 9.5.2 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372 9.5.3 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . . 373 9.5.4 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . 374 9.5.5 Summary of Urodynamic Findings . . . . . . . . . . . . . . . 375 9.5.6 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . . 375 9.5.7 Transrectal Ultrasonography of

Prostate and Non-contrast CT . . . . . . . . . . . . . . . . . . . 376 9.5.8 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 9.5.9 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . . 378 9.5.10 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . 378

9.6 An 80-Year-Old Male with Benign Prostatic Obstruction Presenting with High Fever . . . . . . . . . . 379 9.6.1 Abdominal CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379 9.6.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . . 380 9.6.3 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 9.6.4 Uroflowmetry and PVR Measurement . . . . . . . . . . . . . 382 9.6.5 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383 9.6.6 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . . 384 9.6.7 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . . 385 9.6.8 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . 386 9.6.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . . 387 9.6.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . . 387 9.6.11 Transrectal Ultrasonography of Prostate . . . . . . . . . . . 387 9.6.12 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388 9.6.13 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . . 389 9.6.14 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . 390

9.7 A 70-Year-Old Female with Bladder Outflow Obstruction Presenting with Urinary Retention . . . . . . . . . . . . . . . . . . . . . . 391

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9.7.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391 9.7.2 Uroflowmetry and PVR Measurement . . . . . . . . . . . . . 392 9.7.3 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393 9.7.4 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . . 394 9.7.5 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . . 395 9.7.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . 396 9.7.7 Summary of Urodynamic Findings . . . . . . . . . . . . . . . 397 9.7.8 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . . 397 9.7.9 Electrodiagnostic Test . . . . . . . . . . . . . . . . . . . . . . . . . 397 9.7.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398 9.7.11 Perineal and Transvaginal Ultrasonography . . . . . . . . 399 9.7.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . . 399 9.7.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . 399

9.8 An 85-Year-Old Male with Detrusor Underactivity Presenting with Increased Daytime Frequency . . . . . . . . . . . . 400 9.8.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401 9.8.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . . 402 9.8.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . . 403 9.8.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404 9.8.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . . 405 9.8.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . 406 9.8.7 Summary of Urodynamic Findings . . . . . . . . . . . . . . . 407 9.8.8 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . . 407 9.8.9 Transrectal Ultrasonography of Prostate . . . . . . . . . . . 407 9.8.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408 9.8.11 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . . 408 9.8.12 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . . 409 9.8.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . 410

9.9 A 71-Year-Old Male with Idiopathic Overactive Bladder Presenting with Urgency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 9.9.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 9.9.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . . 412 9.9.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . . 413 9.9.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 9.9.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . . 415 9.9.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . . 416 9.9.7 Summary of Urodynamic Findings . . . . . . . . . . . . . . . 417 9.9.8 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . . 417 9.9.9 Transrectal Ultrasonography of Prostate . . . . . . . . . . . 417 9.9.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418 9.9.11 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . . 419 9.9.12 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . 419

9.10 A 73-Year-Old Male with Detrusor Hyperactivity with Impaired Contractility . . . . . . . . . . . . . . . . 420 9.10.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421

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9.10.2 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 422 9.10.3 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 423 9.10.4 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 424 9.10.5 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 425 9.10.6 Summary of Urodynamic Findings . . . . . . . . . . . . . . 426 9.10.7 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 426 9.10.8 Transrectal Ultrasonography of Prostate . . . . . . . . . . 426 9.10.9 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 427 9.10.10 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 428 9.10.11 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 428

9.11 A 63-Year-Old Female with Stress Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429 9.11.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430 9.11.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 431 9.11.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 432 9.11.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 433 9.11.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 434 9.11.6 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 435 9.11.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 436 9.11.8 Summary of Urodynamic Findings . . . . . . . . . . . . . . 437 9.11.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 437 9.11.10 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 437 9.11.11 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 437

9.12 A 76-Year-Old Female with Anterior Vaginal Wall Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438 9.12.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439 9.12.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 440 9.12.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 441 9.12.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 442 9.12.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 443 9.12.6 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 444 9.12.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 445 9.12.8 Summary of Urodynamic Findings . . . . . . . . . . . . . . 446 9.12.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 446 9.12.10 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 446 9.12.11 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 446

9.13 A 72-Year-Old Male with Urodynamic Stress Urinary Incontinence After Radical Prostatectomy . . . . . . . . . . . . . . . . 447 9.13.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448 9.13.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 449 9.13.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 450 9.13.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 451 9.13.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 452 9.13.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 453 9.13.7 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 454

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9.13.8 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 455 9.13.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . 456 9.13.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 456 9.13.11 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 457 9.13.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 458 9.13.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 458

9.14 A 74-Year-Old Male with Urgency Incontinence After Radical Prostatectomy . . . . . . . . . . . . . . . . 459 9.14.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460 9.14.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 461 9.14.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 462 9.14.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 463 9.14.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 464 9.14.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 465 9.14.7 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 466 9.14.8 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 467 9.14.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . 468 9.14.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 468 9.14.11 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 469 9.14.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 470 9.14.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 470

9.15 A 79-Year-Old Male with Post-Prostatectomy Urinary Incontinence Presenting Abdominal Straining to Void . . . . . . 471 9.15.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471 9.15.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 472 9.15.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 473 9.15.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 474 9.15.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 475 9.15.6 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 476 9.15.7 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 477 9.15.8 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 478 9.15.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . 479 9.15.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 479 9.15.11 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 480 9.15.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 481 9.15.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 481

9.16 A 33-Year-Old Male on Intermittent Catheterization Following Augmentation Ileocystoplasty . . . . 482 9.16.1 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 482 9.16.2 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 483 9.16.3 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 484 9.16.4 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 485 9.16.5 Summary of Urodynamic Findings . . . . . . . . . . . . . . 486 9.16.6 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 486 9.16.7 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487

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9.16.8 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 487 9.16.9 Preoperative Cystometry . . . . . . . . . . . . . . . . . . . . . . 488 9.16.10 Preoperative Fluoroscopy During UDS . . . . . . . . . . . 489 9.16.11 Preoperative Urethral Pressure Profile . . . . . . . . . . . . 490 9.16.12 Summary of Pre-op Urodynamic Findings . . . . . . . . 491 9.16.13 Preoperative CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491 9.16.14 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 491

9.17 A 25-Year-Old Male with Persistent Urinary Incontinence After Augmentation Cystoplasty . . . . . . . . . . . . 492 9.17.1 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 493 9.17.2 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 494 9.17.3 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 495 9.17.4 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 496 9.17.5 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 497 9.17.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 498 9.17.7 Summary of Urodynamic Findings . . . . . . . . . . . . . . 499 9.17.8 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 499 9.17.9 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 500 9.17.10 Non-contrast CT and Renal Scan . . . . . . . . . . . . . . . . 501 9.17.11 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 502 9.17.12 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 502

9.18 A 75-Year-Old Female with Interstitial Cystitis Presenting with Bladder Pain . . . . . . . . . . . . . . . . . . . . . . . . . . 503 9.18.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504 9.18.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 505 9.18.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 506 9.18.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 507 9.18.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 508 9.18.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 509 9.18.7 Summary of Urodynamic Findings . . . . . . . . . . . . . . 510 9.18.8 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 510 9.18.9 Cystoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511 9.18.10 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 511 9.18.11 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 511

9.19 A 70-Year-Old Male with Bladder Overdistension Secondary to Acute Urinary Retention . . . . . . . . . . . . . . . . . . 512 9.19.1 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 513 9.19.2 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 514 9.19.3 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 515 9.19.4 Summary of Urodynamic Findings . . . . . . . . . . . . . . 516 9.19.5 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 516 9.19.6 Transrectal Ultrasonography of Prostate . . . . . . . . . . 516 9.19.7 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 517 9.19.8 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 517 9.19.9 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 517

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9.20 An 81-Year-Old Male with Bladder Diverticulum Presenting with Lower Urinary Tract Symptoms . . . . . . . . . . 518 9.20.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519 9.20.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 520 9.20.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 521 9.20.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 522 9.20.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 523 9.20.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 524 9.20.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 525 9.20.8 Summary of Urodynamic Findings . . . . . . . . . . . . . . 526 9.20.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 526 9.20.10 Transrectal Ultrasonography of Prostate . . . . . . . . . . 526 9.20.11 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 527 9.20.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 527 9.20.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 527

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528

10 Brain Lesions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 529 10.1 A 44-Year-Old Male with a History of 

Stroke Presenting with Urgency . . . . . . . . . . . . . . . . . . . . . . . 529 10.1.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530 10.1.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 531 10.1.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 532 10.1.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 533 10.1.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 534 10.1.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 535 10.1.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 536 10.1.8 Summary of Urodynamic Findings . . . . . . . . . . . . . . 537 10.1.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 537 10.1.10 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 537 10.1.11 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 537

10.2 A 73-Year-Old Male with Parkinson’s Disease Presenting with Slow Stream . . . . . . . . . . . . . . . . . . . . . . . . . . 538 10.2.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539 10.2.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 540 10.2.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 541 10.2.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 542 10.2.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 543 10.2.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 544 10.2.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 545 10.2.8 Summary of Urodynamic Findings . . . . . . . . . . . . . . 546 10.2.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 546 10.2.10 Cystourethroscopy and Transrectal

Ultrasonography of Prostate . . . . . . . . . . . . . . . . . . . 547

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10.2.11 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548 10.2.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 548 10.2.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 548

10.3 A 55-Year-Old Male with Cerebellar Ataxia Presenting with Urgency Incontinence . . . . . . . . . . . . . . . . . . 549 10.3.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549 10.3.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 550 10.3.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 551 10.3.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 552 10.3.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 553 10.3.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 554 10.3.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 555 10.3.8 Summary of Urodynamic Findings . . . . . . . . . . . . . . 556 10.3.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 556 10.3.10 Brain MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557 10.3.11 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 557 10.3.12 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 557

10.4 A 54-Year-Old Male with Multiple System Atrophy Presenting with Urinary Incontinence . . . . . . . . . . . . 558 10.4.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559 10.4.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 560 10.4.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 561 10.4.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 562 10.4.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 563 10.4.6 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 564 10.4.7 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 565 10.4.8 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 566 10.4.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . 567 10.4.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 567 10.4.11 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 568 10.4.12 Transrectal Ultrasonography of

Prostate and Brain MRI . . . . . . . . . . . . . . . . . . . . . . . 569 10.4.13 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 569 10.4.14 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 569

10.5 A 76-Year-Old Male with Alzheimer’s Disease Presenting with Urgency . . . . . . . . . . . . . . . . . . . . . . 570 10.5.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571 10.5.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 572 10.5.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 573 10.5.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 574 10.5.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 575 10.5.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 576 10.5.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 577 10.5.8 Summary of Urodynamic Findings . . . . . . . . . . . . . . 578

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10.5.9 Urodynamic Conclusion (Modified from ICS Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 578

10.5.10 Transrectal Ultrasonography of Prostate . . . . . . . . . . 578 10.5.11 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 579 10.5.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 580 10.5.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 580

10.6 A 21-Year-Old Female with Mental Retardation Presenting with Urgency Incontinence . . . . . . . . . . . . . . . . . . 581 10.6.1 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 581 10.6.2 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 582 10.6.3 Filling Cystometry (First) . . . . . . . . . . . . . . . . . . . . . 583 10.6.4 Filling Cystometry (Second) . . . . . . . . . . . . . . . . . . . 584 10.6.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 585 10.6.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 586 10.6.7 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 587 10.6.8 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 588 10.6.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . 589 10.6.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 589 10.6.11 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 590 10.6.12 Abdominal Ultrasonography . . . . . . . . . . . . . . . . . . . 590 10.6.13 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 591 10.6.14 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 591

10.7 A 53-Year-Old Male with Schizophrenia Presenting with Urgency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592 10.7.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592 10.7.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 593 10.7.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 594 10.7.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 595 10.7.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 596 10.7.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 597 10.7.7 Summary of Urodynamic Findings . . . . . . . . . . . . . . 598 10.7.8 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 598 10.7.9 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 598 10.7.10 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 598

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599

11 Spinal Lesions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 601 11.1 A 61-Year-Old Male with T12 Spinal Cord Injury

Showing Continued Abdominal Straining to Void. . . . . . . . . . 601 11.1.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602 11.1.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 603 11.1.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 604 11.1.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 605 11.1.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 606 11.1.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 607 11.1.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 608 11.1.8 Summary of Urodynamic Findings . . . . . . . . . . . . . . 609

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11.1.9 Urodynamic Conclusion (Modified from ICS Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 609

11.1.10 Non-contrast CT and Cystoscopy . . . . . . . . . . . . . . . 610 11.1.11 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 610 11.1.12 Frequency-Volume Chart at

Postoperative Sixth Month . . . . . . . . . . . . . . . . . . . . . 611 11.1.13 Non-contrast CT at Postoperative Sixth Month . . . . . 612 11.1.14 Filling Cystometry at Postoperative Sixth Month . . . 612 11.1.15 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 613

11.2 A 19-Year-Old Male with T9 Spinal Cord Injury Showing Urinary Incontinence in Between Catheterization . . . . . . . . . . 614 11.2.1 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 615 11.2.2 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 616 11.2.3 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 617 11.2.4 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 618 11.2.5 Summary of Urodynamic Findings . . . . . . . . . . . . . . 619 11.2.6 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 619 11.2.7 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 620 11.2.8 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621 11.2.9 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 621 11.2.10 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 622

11.3 A 49-Year-Old Male with L1 Spinal Fracture Presenting with Insensible Urinary Incontinence . . . . . . . . . . 623 11.3.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624 11.3.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 625 11.3.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 626 11.3.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 627 11.3.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 628 11.3.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 629 11.3.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 630 11.3.8 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 631 11.3.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . 632 11.3.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 632 11.3.11 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 633 11.3.12 Imaging Study: Non-contrast Kidney CT . . . . . . . . . 634 11.3.13 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 635 11.3.14 Intraoperative Findings and

Postoperative Progress . . . . . . . . . . . . . . . . . . . . . . . . 635 11.3.15 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 636

11.4 A 65-Year-Old Male with L3 Spinal Cord Disease Presenting with Urgency Urinary Incontinence . . . . . 637 11.4.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638 11.4.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 639 11.4.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 640 11.4.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 641 11.4.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 642

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11.4.6 Abdominal Leak Point Pressure. . . . . . . . . . . . . . . . . 643 11.4.7 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 644 11.4.8 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 645 11.4.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . 646 11.4.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 646 11.4.11 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647 11.4.12 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 647 11.4.13 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 648 11.4.14 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 648

11.5 A 43-Year-Old Male with L-Spine Ependymoma Presenting with Urinary Incontinence on Walking . . . . . . . . . 649 11.5.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 650 11.5.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 651 11.5.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 652 11.5.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 65311.5.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 654 11.5.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 655 11.5.7 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 656 11.5.8 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 657 11.5.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . 658 11.5.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 658 11.5.11 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 659 11.5.12 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659 11.5.13 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 660 11.5.14 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 660

11.6 A 60-Year-Old Male with C4 Spinal Cord Injury Presenting with Ineffective Bladder Reflex Triggering . . . . . . 661 11.6.1 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 661 11.6.2 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 662 11.6.3 Filling and Pressure-Flow Study . . . . . . . . . . . . . . . . 663 11.6.4 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 664 11.6.5 Summary of Urodynamic Findings . . . . . . . . . . . . . . 666 11.6.6 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 666 11.6.7 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 667 11.6.8 Non-contrast CT and Transrectal

Ultrasonography of Prostate . . . . . . . . . . . . . . . . . . . 668 11.6.9 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 669 11.6.10 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 669

11.7 A 46-Year-Old Female with Multiple Sclerosis Presenting with Urgency Urinary Incontinence . . . . . . . . . . . . 670 11.7.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671 11.7.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 672 11.7.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 673 11.7.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 674 11.7.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 675

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11.7.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . 676 11.7.7 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . 677 11.7.8 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . 678 11.7.9 Summary of Urodynamic Findings . . . . . . . . . . . . . 679 11.7.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . 679 11.7.11 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 680 11.7.12 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . 680 11.7.13 CNS MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681 11.7.14 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . 682 11.7.15 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . 682

11.8 A 45-Year-Old Female with Behcet’s Disease Presenting with Voiding Difficulty and Urinary Incontinence . . . . . . . . 683

11.8.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 684 11.8.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . 685 11.8.3 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . 686 11.8.4 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . 687 11.8.5 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . 688 11.8.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . 689 11.8.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . 690 11.8.8 Summary of Urodynamic Findings . . . . . . . . . . . . . 691 11.8.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . 691 11.8.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . 692 11.8.11 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 693 11.8.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . 693 11.8.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . 693

11.9 A 22-Year-Old Female with Lupus Myelitis Presenting with Urgency Urinary Incontinence . . . . . . . . . . . 694

11.9.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 695 11.9.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . 696 11.9.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . 697 11.9.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . 698 11.9.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . 699 11.9.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . 700 11.9.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . 701 11.9.8 Summary of Urodynamic Findings . . . . . . . . . . . . . 702 11.9.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . 702 11.9.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . 703 11.9.11 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 703 11.9.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . 703 11.9.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . 703

11.10 A 53-Year-Old Male with T6 Myelopathy Presenting with Urgency Urinary Incontinence . . . . . . . . . . . . . . . . . . . . 704

11.10.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 705 11.10.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . 706 11.10.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . 707

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11.10.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . 708 11.10.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . 709 11.10.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . 710 11.10.7 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . 711 11.10.8 Summary of Urodynamic Findings . . . . . . . . . . . . 712 11.10.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . 712 11.10.10 Summary and Progress . . . . . . . . . . . . . . . . . . . . . 712 11.10.11 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . 712

11.11 A 21-Year-Old Ambulatory Male with Lumbosacral Lipoma Presenting with Late Onset of Voiding Difficulty . . . 713

11.11.1 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . 714 11.11.2 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . 715 11.11.3 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . 716 11.11.4 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . 717 11.11.5 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . 718 11.11.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . 719 11.11.7 Summary of Urodynamic Findings . . . . . . . . . . . . 720 11.11.8 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . 720 11.11.9 Non-contract NECT and DMSA Renal Scan. . . . . 721 11.11.10 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721 11.11.11 Clinical Progress . . . . . . . . . . . . . . . . . . . . . . . . . . 722 11.11.12 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . 722

11.12 An 11-Year-Old Female with  Lipomeningomyelocele Presenting with Urosepsis . . . . . . . . 723

11.12.1 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . 724 11.12.2 Uroflowmetry and PVR Measurement . . . . . . . . . . 725 11.12.3 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . 726 11.12.4 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . 727 11.12.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . 728 11.12.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . 729 11.12.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . 730 11.12.8 Summary of Urodynamic Findings . . . . . . . . . . . . 731 11.12.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . 731 11.12.10 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . 731 11.12.11 Summary and Progress . . . . . . . . . . . . . . . . . . . . . 732 11.12.12 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . 732

11.13 A 25-Year-Old Female with Meningomyelocele Presenting with Urinary Incontinence and Recent Acute Pyelonephritis . . . . . . . . . . . . . . . . . . . . . . 733

11.13.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734 11.13.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . 735 11.13.3 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . 736 11.13.4 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . 737 11.13.5 Simultaneous Fluoroscopy During UDS . . . . . . . . 738 11.13.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . 739

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11.13.7 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . 740 11.13.8 Summary of Urodynamic Findings . . . . . . . . . . . . 741 11.13.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . 741 11.13.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . 742 11.13.11 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . 743 11.13.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . 743 11.13.13 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . 744 11.13.14 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . 744

11.14 A 28-Year-Old Male with T10 Intradural Arteriovenous Fistula Presenting with Voiding Difficulty . . . . . . . . . . . . . . 745

11.14.1 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . 745 11.14.2 Uroflowmetry and PVR Measurement . . . . . . . . . . 746 11.14.3 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . 747 11.14.4 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . 748 11.14.5 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . 749 11.14.6 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . 750 11.14.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . 751 11.14.8 Summary of Urodynamic Findings . . . . . . . . . . . . 752 11.14.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . 752 11.14.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . 753 11.14.11 Spine MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 754 11.14.12 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . 754 11.14.13 DTPA Renal Scan . . . . . . . . . . . . . . . . . . . . . . . . . 754 11.14.14 Summary and Progress . . . . . . . . . . . . . . . . . . . . . 755 11.14.15 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . 755

11.15 A 52-Year-Old Male with Lumbar Herniated Intervertebral Disc Surgery Presenting with  Daytime Urgency Urinary Incontinence . . . . . . . . . . . . . . . . 756

11.15.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 757 11.15.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . 758 11.15.3 Uroflowmetry and PVR Measurement . . . . . . . . . . 759 11.15.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . 760 11.15.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . 761 11.15.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . 762 11.15.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . 763 11.15.8 Summary of Urodynamic Findings . . . . . . . . . . . . 764 11.15.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . 764 11.15.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . 764 11.15.11 Electrodiagnostic Test . . . . . . . . . . . . . . . . . . . . . . 765 11.15.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . 765 11.15.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . 765

11.16 A 54-Year-Old Male with Sacral Chordoma Presenting with Voiding Difficulty and Cough-Induced Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 766

11.16.1 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . 766

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11.16.2 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . 767 11.16.3 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . 768 11.16.4 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . 769 11.16.5 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . 770 11.16.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . 771 11.16.7 Summary of Urodynamic Findings . . . . . . . . . . . . . 772 11.16.8 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . 772 11.16.9 Contrast CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 773 11.16.10 Pelvis MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 773 11.16.11 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . 773 11.16.12 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . 773

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 774

12 Peripheral Lesions and Miscellaneous � � � � � � � � � � � � � � � � � � � � 775 12.1 A 77-Year-Old Female Presenting with Bilateral

Hydronephrosis After Radical Hysterectomy . . . . . . . . . . . . . 775 12.1.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776 12.1.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 777 12.1.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 778 12.1.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 779 12.1.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 780 12.1.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 781 12.1.7 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 782 12.1.8 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 783 12.1.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . 784 12.1.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 784 12.1.11 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 785 12.1.12 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 785 12.1.13 Summary and Progress (1) . . . . . . . . . . . . . . . . . . . . . 785 12.1.14 Progress (2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 785 12.1.15 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 786

12.2 A 54-Year-Old Female Presenting with Bilateral Hydronephrosis After Radiation Therapy for  Uterine Cervical Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 787 12.2.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 788 12.2.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 789 12.2.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 790 12.2.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 791 12.2.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 792 12.2.6 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 793 12.2.7 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 794 12.2.8 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 795 12.2.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . 796 12.2.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 796

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12.2.11 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 797 12.2.12 Imaging Study: Non-contrast CT . . . . . . . . . . . . . . . . 797 12.2.13 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 798 12.2.14 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 798

12.3 A 65-Year-Old Female with Diabetic Neurogenic Bladder Presenting with Storage Symptoms . . . . . . . . . . . . . . 799 12.3.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800 12.3.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 801 12.3.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 802 12.3.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 803 12.3.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 804 12.3.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 805 12.3.7 Urodynamic Stress Test . . . . . . . . . . . . . . . . . . . . . . . 806 12.3.8 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 807 12.3.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . 808 12.3.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 808 12.3.11 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 809 12.3.12 Abdominal Ultrasonography . . . . . . . . . . . . . . . . . . . 809 12.3.13 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 810 12.3.14 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 810

12.4 A 67-Year-Old Male with Poor General Performance Presenting with Acute Urinary Retention . . . . . 811 12.4.1 Clinical Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811 12.4.2 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 812 12.4.3 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 813 12.4.4 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 814 12.4.5 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 815 12.4.6 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 816 12.4.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 817 12.4.8 Summary of Urodynamic Findings . . . . . . . . . . . . . . 818 12.4.9 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 818 12.4.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 819 12.4.11 Transrectal Ultrasonography of Prostate . . . . . . . . . . 819 12.4.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 820 12.4.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 820

12.5 A 54-Year-Old Male with  Medication-Induced Voiding Dysfunction . . . . . . . . . . . . . . . . 821 12.5.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 822 12.5.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 823 12.5.3 Uroflowmetry and PVR Measurement . . . . . . . . . . . . 824 12.5.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 825 12.5.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 826 12.5.6 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 827 12.5.7 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 828 12.5.8 Summary of Urodynamic Findings . . . . . . . . . . . . . . 829

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12.5.9 Urodynamic Conclusion (Modified from ICS Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 829

12.5.10 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 830 12.5.11 Transrectal Ultrasonography of Prostate . . . . . . . . . . 831 12.5.12 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 831 12.5.13 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 831

12.6 An 18-Year-Old Male with Dysfunctional Voiding . . . . . . . . . 832 12.6.1 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 833 12.6.2 Frequency-Volume Chart . . . . . . . . . . . . . . . . . . . . . . 834 12.6.3 Flow-EMG and PVR Measurement . . . . . . . . . . . . . . 835 12.6.4 Filling Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 836 12.6.5 Pressure-Flow Study . . . . . . . . . . . . . . . . . . . . . . . . . 837 12.6.6 Pressure-Flow Study (Magnified) . . . . . . . . . . . . . . . 838 12.6.7 Fluoroscopy During UDS . . . . . . . . . . . . . . . . . . . . . 839 12.6.8 Urethral Pressure Profile . . . . . . . . . . . . . . . . . . . . . . 840 12.6.9 Summary of Urodynamic Findings . . . . . . . . . . . . . . 841 12.6.10 Urodynamic Conclusion (Modified from ICS

Classification, 2002 and 2018) . . . . . . . . . . . . . . . . . . 841 12.6.11 Non-contrast CT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 841 12.6.12 Cystourethroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 842 12.6.13 Summary and Progress . . . . . . . . . . . . . . . . . . . . . . . 842 12.6.14 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . 843References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 844

Erratum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E1

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AD Autonomic dysreflexiaALPP Abdominal leak point pressureAPN Acute pyelonephritisBCR Bulbocavernosus reflexBOO Bladder outflow obstruction, bladder outlet obstructionBPH Benign prostatic hyperplasiaCIC Clean intermittent catheterizationDLPP Detrusor leak point pressureDO Detrusor overactivityDRE Digital rectal examinationDSD Detrusor-sphincter dyssynergiaDU Detrusor underactivityEMG ElectromyographyFPL Functional profile lengthICS International Continence SocietyIDC Involuntary detrusor contractionLUTD Lower urinary tract dysfunctionLUTS Lower urinary tract symptomsMCC Maximum cystometric capacityMUCP Maximum urethral closure pressureOAB Overactive bladderPabd Abdominal pressurePdet Detrusor pressurePFS Pressure-flow studyPiso Isometric pressurePPI Post-prostatectomy incontinencePSA Prostate-specific antigenPves Intravesical pressurePVR Postvoid residualQmax Maximum flow rateSUI Stress urinary incontinenceTRUS Transrectal ultrasonographyUPP Urethral pressure profileUDS Urodynamic studyVCUG Voiding cystourethrographyVLPP Valsalva leak point pressureVUR Vesicoureteral reflux

Abbreviations

xli

Seung-June Oh is currently a Professor of Urology at Seoul National University (SNU) College of Medicine in Seoul, South Korea. After complet-ing his undergraduate and graduate studies at SNU, Professor Oh pursued a clinical fellowship at the Asan Medical Center in Seoul and research fellow-ship at Seoul National University Hospital (SNUH) and the University of Michigan, Ann Arbor, in the USA. He is a full-time faculty member of the Department of Urology at SNUH, specializing in neurourology and recon-structive surgery.

Professor Oh has been interested in lower urinary tract dysfunction since his residency and conducted research on postoperative urinary dysfunctions in rectal cancer patients. He earned his master’s degree at SNU College of Medicine through his research “The Effect of Intravesical Oxybutynin Instillation in Experimental Rat” using in vivo cystometry. During his fellow-ship at SNUH, he was involved in basic physiologic research of bladder smooth muscles using organ bath and obtained his PhD on the topic of “Contractile Properties of Adult and Neonatal Bladder Smooth Muscle.” Afterward, Professor Oh was appointed as an Assistant Professor and was the first to subspecialize in lower urinary tract dysfunction at the Department of

About the Author

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Urology in SNU College of Medicine and SNUH in 2000. He was promoted as a Professor since 2010.

Feeling the need for more clinical knowledge and experience on patients with spinal injury, the most severe form of lower uninary tract dysfunction, Professor Oh went abroad in 2003 to study under the supervision of Professor Edward J. McGuire at the University of Michigan, Ann Arbor for two years. After returning to SNUH, Professor Oh renovated fluoroscopic UDS system and newly set up Clean Intermittent Catheterization Center. He has also developed a UDS database registry system. In 2008, Professor Oh started an annual educational program of ‘Intensive Course on UDS Interpretation’ for training residents as a full day course.

Over the past 25 years, Professor Oh has authored or coauthored over 220 peer-reviewed papers and contributed to 15 book chapters, including a chap-ter in the ninth edition of Campbell’s Urology textbook as the first author. He was also featured as the principal investigator in 103 different researches on the lower urinary tract dysfunction areas. His primary interest is in benign prostatic hyperplasia (BPH), overactive bladder, and neuropathic lower uri-nary tract dysfunction. He is interested in research on the urodynamic aspect of bladder outflow obstruction associated with BPH and also in the Holmium laser enucleation of the prostate or HoLEP for BPH. In addition to his medi-cal specialty, Professor Oh holds medical device-related positions: he is the General Director of the Medical Device Innovation Center and also Director of the Medical Device Usability Testing Center of SNUH.

Professor Oh is an active member of several professional organizations, including the International Continence Society, American Urological Association, and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. He had been served as the President of the Korean Continence Society since January 2016 and served as the President of the Pan-Pacific Continence Society.

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