Q: Analyse this urodynamic study and comment A: I now have all the data I need from the images and the textbook reference. Let me compile a thorough analysis. --- Urodynamic Study Analysis - Kumavat, Mahendrakumar Male, 58 yrs, Patient 3419 Study type: Pressure-flow study MMS system, performed 09/06/2026 at Sujay Urological Hospital, Investigator: Dr. Ajay Bhandarkar --- Patient Summary Parameter Value ------ Gender Male Age 58 years DOB 15/07/1967 --- 1. FILLING PHASE ANALYSIS Cystometric Capacity & Bladder Volumes Sensation Volume ml Pdet cmH₂O --------- First sensation 97 ml 1 First desire 165 ml 0 Normal desire 302 ml 3 Strong desire 469 ml 11 Urgency 497 ml 7 MCC 497 ml 9 Infused volume: 492 ml Bladder filling: 492 ml No leakage Comments on filling: - Sensations are normal and occur at physiologically appropriate volumes. First sensation at 97 ml, normal desire at 302 ml, and MCC at 497 ml are all within accepted ranges. - Bladder compliance is excellent. The Pdet compliance linear regression = 921 ml/cmH₂O - this is exceptionally high. Normal compliance is 20 ml/cmH₂O, so this value confirms a highly compliant, non-stiff bladder. No evidence of detrusor overactivity during filling. - No detrusor overactivity DO is recorded during the entire filling phase. The Pdet tracing remains flat and close to baseline throughout filling. - No stress urinary incontinence - cough tests 13 cough spikes seen in the marker table show appropriate Pves and Pabd rises that cancel out in Pdet, confirming good catheter function and no leakage on cough. - The EMG tracing shows appropriate activity. Filling phase conclusion: Normal cystometry - good compliance, no detrusor overactivity, normal bladder sensation. --- 2. VOIDING PHASE ANALYSIS Voiding Parameters Parameter Value Comment --------- Total bladder capacity 492 ml Qmax 17.2 ml/s Low-normal/borderline Time to Qmax 43 s Prolonged normal 30s Pdet at Qmax 29 cmH₂O See below Voided volume 503 ml Flow time 95 s Voiding time 178 s Significantly prolonged Hesitancy 32 s Significantly prolonged normal 8s Average flow rate 5.3 ml/s Low normal 10 ml/s Computed residual urine -11 ml effectively 0 Complete emptying Key observation: There is marked discordance between a relatively preserved Qmax 17.2 ml/s and a very low average flow rate 5.3 ml/s, combined with prolonged voiding time 178 s and significant hesitancy 32 s. This pattern suggests intermittent/interrupted flow or a prolonged, straining, drawn-out void with a poor flow curve shape - consistent with bladder outlet obstruction BOO or impaired detrusor contractility. --- 3. NOMOGRAM ANALYSIS Siroky Nomogram The plot shows: - Average flow rate point falls in the obstructed zone average flow 5 ml/s at bladder volume 503 ml - well below the mean-2SD line - Qmax point falls at the lower end of the normal/borderline range 17 ml/s at 503 ml - just at the -1 SD line This divergence between average and maximum flow is characteristic of poor sustained detrusor contraction or outlet obstruction with intermittent flow. Liverpool Nomogram - Average flow rate 5 ml/s at 503 ml voided is in the below-normal range - Qmax 17 ml/s is at the lower-normal boundary Detrusor-Flow ICS Plot - Abrams-Griffiths / BOOI - A/G number BOOI = -5 - The ICS detrusor-flow plot classifies this as UNOBSTRUCTED BOOI 20 is unobstructed; equivocal 20-40; obstructed 40 - The plot shows the tracing falls in the unobstructed zone, though close to the equivocal line - Bladder Contractility Index BCI can be estimated: BCI = Pdet.Qmax + 5×Qmax = 29 + 5×17.2 = 29 + 86 = 115 - this is in the normal contractility range 100 = normal, 100-150 = normal --- 4. INTEGRATED INTERPRETATION BOOI and BCI Calculation Using the standard ICS equations: - BOOI Bladder Outlet Obstruction Index = Pdet.Qmax - 2×Qmax = 29 - 2×17.2 = 29 - 34.4 = -5.4 → Unobstructed - BCI Bladder Contractility Index = Pdet.Qmax + 5×Qmax = 29 + 86 = 115 → Normal contractility Per ICS criteria: - BOOI 40 = obstructed - BOOI 20-40 = equivocal - BOOI 20 = unobstructed this patient = -5, clearly unobstructed The Diagnostic Dilemma This patient presents an interesting pattern: 1. BOOI says unobstructed Pdet at Qmax only 29 cmH₂O, Qmax 17.2 ml/s 2. Yet average flow rate is markedly reduced 5.3 ml/s, voiding time is prolonged 178 s, and hesitancy is 32 s 3. BCI is normal 115, ruling out overt detrusor underactivity This combination - normal BOOI + low average flow + prolonged voiding time + hesitancy - is most consistent with: - Dysfunctional voiding / intermittent detrusor contraction - the detrusor can generate adequate pressure Pdet.Qmax = 29 but cannot sustain it throughout voiding, resulting in interrupted or weak sustained flow hence low average rate despite reasonable peak - Functional bladder outlet obstruction - possibly early or dynamic BOO that is not captured at the moment of Qmax but impedes average flow - In a 58-year-old male, benign prostatic obstruction BPO remains clinically likely and must be correlated with IPSS score, uroflowmetry, PSA, and prostate size on TRUS/TRUS biopsy Residual Urine - Computed residual = -11 ml effectively zero - complete bladder emptying, which is reassuring. --- 5. QUALITY OF STUDY - Technically acceptable study. Cough tests throughout filling confirm appropriate pressure transmission and catheter function. - Pves and Pabd tracings track together on coughs Pdet remains stable, confirming the rectal line is functional. - The Pdet values during voiding are low max 29 cmH₂O, suggesting the patient did NOT strain significantly during voiding - this is a true detrusor-generated void. --- 6. SUMMARY REPORT Domain Finding ------ Filling phase Normal - no detrusor overactivity, normal compliance 921 ml/cmH₂O, normal sensations Bladder capacity 492 ml normal-to-large Voiding Reduced average flow 5.3 ml/s, prolonged voiding time and hesitancy, Qmax 17.2 ml/s Detrusor pressure Low-normal Pdet at Qmax 29 cmH₂O BOOI -5 Unobstructed by ICS criteria BCI 115 Normal detrusor contractility Post-void residual 0 ml complete emptying Overall diagnosis Impaired detrusor contractility with dysfunctional voiding pattern; no urodynamic evidence of bladder outlet obstruction; no detrusor overactivity --- 7. CLINICAL RECOMMENDATIONS 1. Correlate with clinical symptoms - if this patient presents with LUTS/obstructive symptoms, the urodynamics do NOT confirm urodynamic BOO. Empirical treatment for BPO alpha-blockers, 5-ARIs may still be appropriate if IPSS is high and prostate is enlarged on imaging. 2. Consider dysfunctional voiding - prolonged hesitancy 32 s and low average flow despite normal peak and pressure suggests impaired detrusor sustaining ability. Pelvic floor dysfunction should be excluded. 3. The low average flow rate 5.3 ml/s with normal Qmax 17.2 ml/s can occur with a flat, interrupted flow curve - a free uroflowmetry with flow curve shape review would be complementary. 4. No anticholinergics/antimuscarinics indicated - no detrusor overactivity detected. 5. No evidence of upper tract risk - excellent compliance, no high-pressure filling. 6. Follow-up urodynamics may be useful if symptoms progress, to reassess whether BOOI evolves into the equivocal/obstructed range. --- Interpretation based on ICS standardisation Abrams et al. and Campbell-Walsh-Wein Urology criteria for BOOI and BCI. Clinical correlation with history, prostate assessment, and symptom scores is essential before management decisions.
