• Conditions – kidney stones, UTIs, BPH, prostate cancer, bladder cancer, incontinence, erectile dysfunction, etc.
• Procedures – cystoscopy, TURP, nephrectomy, lithotripsy, vasectomy, etc.
• Anatomy – kidneys, ureters, bladder, urethra, prostate, testes
• Diagnostics – urinalysis, PSA, imaging, urodynamics
• Medications – alpha-blockers, 5-ARIs, anticholinergics, etc.

Urodynamic Study Analysis — Patel, Hashumati

Patient Demographics & Context

Filling Phase Analysis

• Severely reduced functional bladder capacity (38 ml) — normal is typically 300–600 ml. This is a critically small capacity.
• Large volume lost through leakage (94 ml) — occurring during the filling phase, this strongly suggests stress urinary incontinence (SUI) or urodynamic stress incontinence (USI). The cough markers confirm leak episodes:
  • Cough [1] at 0:03:28 → Pves spike to 28 cmH₂O, Pabd 19 cmH₂O, Pdet = 9 cmH₂O → leakage likely occurred
  • Cough [3] at 0:08:26 → Pdet 14 cmH₂O
• Pdet during filling remains relatively low and stable between coughs — no clear involuntary detrusor contractions are seen, suggesting no detrusor overactivity (DO) during filling. Bladder compliance appears preserved.
• The Pves and Pabd traces track each other during coughs, with Pdet rising only transiently — consistent with genuine stress incontinence (leakage driven by abdominal pressure rise, not detrusor contraction).

Voiding Phase Analysis

• Severely diminished flow rate (Qmax 3.3 ml/s) — markedly below the expected ≥15 ml/s in females
• However, this must be interpreted in the context of the extremely small voided volume (31 ml) — flow rates are unreliable and typically low when voided volumes are <150 ml. The Liverpool nomogram plots confirm the data point falls at the very low end (<5th percentile) for both Qmax and average flow rate, but this is largely driven by the tiny voided volume
• Pdet at Qmax is only 20 cmH₂O — low detrusor pressure during voiding
• PVR of 7 ml — the bladder empties what little it stores, so true urinary retention is not present

Detrusor-Flow Plot (ICS Nomogram)

• The data point plots in the "Unobstructed" zone
• A/G number: 14 — confirms unobstructed voiding (A/G <20 = unobstructed in females; this is based on the Blaivas-Groutz nomogram equivalent for females)
• This excludes bladder outlet obstruction (BOO) as the primary diagnosis

Cough Test / Leak Point Pressures

• Leakage occurring at low Pves (as low as 8 cmH₂O) during coughing is consistent with intrinsic sphincter deficiency (ISD) — the most severe form of SUI, where the urethral sphincter mechanism is fundamentally weak
• In a 74-year-old woman, ISD is the predominant mechanism of SUI

Overall Interpretation

Primary Diagnosis: Urodynamic Stress Incontinence (USI) — likely with Intrinsic Sphincter Deficiency (ISD)

• Massive leakage (94 ml out of 132 ml infused) during filling, triggered by coughing/physical stress
• No detrusor overactivity detected
• Unobstructed voiding on ICS nomogram (A/G = 14)
• Leak at low vesical pressures suggesting ISD

Secondary Finding: Severely Reduced Functional Bladder Capacity (38 ml)

• This could be secondary to chronic SUI (bladder never fills fully), or may reflect a sensory urgency/hypersensitive bladder
• Needs correlation with bladder diary and clinical symptoms

No Evidence Of:

• Detrusor overactivity
• Bladder outlet obstruction
• Detrusor underactivity (adequate emptying of stored volume)
• High-pressure retention

Clinical Recommendations

1. Anti-incontinence surgery — given confirmed USI with likely ISD in a 74-year-old:
   • Mid-urethral sling (MUS) — retropubic (TVT) or transobturator (TOT) are first-line surgical options
   • Bulking agents — reasonable option for ISD, especially in elderly patients with surgical risk
   • Artificial urinary sphincter — considered for severe ISD refractory to sling
2. Pelvic floor physiotherapy — as adjunct or if surgery is declined/deferred
3. Bladder diary — to assess functional capacity in a more natural setting and exclude hypersensitive bladder
4. Cystoscopy — to rule out bladder pathology given the very small capacity
5. Repeat urodynamics with a longer filling period may help characterize bladder compliance and capacity more accurately

Note: The very small bladder capacity (38 ml) may have artifactually reduced the voiding parameters. Interpretation of Qmax and flow rates is only reliable with voided volumes >150 ml. The primary actionable finding remains the large-volume stress urinary incontinence consistent with ISD.