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MRCP, FRCR
tumours
poor sphincter relaxationneurogenic causes or anxiety
detrusor weaknesslong-term untreated bladder outlet
ineffective emptyingacontractile detrusor, bladder diverticulae or cystocoeles.
doi: 10.1259/imaging.
20120017
2013 The British Institute of
Radiology
Cite this article as: Sahdev A. Functional imaging of the bladder. Imaging 2013;22:20120017.
imaging.birjournals.org
A Sahdev
control while the sympathetic system (found predominantly in the bladder base) principally controls the
vasculature. Additional sensorimotor nerves are found
in the bladder wall; their precise function is unclear.
The spinal segments S2S4 contain the efferent parasympathetic supply, and T10L2 nerves contain the
sympathetic efferent nerves. After leaving the sacral
foramina, the pelvic splanchnic nerves containing the
parasympathetic neurones pass lateral to the rectum and
enter the inferior pelvic plexus (hypogastric plexus).
These combine with the hypogastric nerve containing the
sympathetic plexus and form the neural plexus at the
nocturia, urgency, incontinence and abnormal sensation. Symptoms relating to abnormal voiding are slow
stream, straining and hesitancy. Post-micturition disorders are usually dribbling and incomplete bladder
emptying.
Storage of urine
The normal bladder should comfortably hold
400500 ml without any increase in the detrusor pressure
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Bladder compliance
Smooth muscle in the bladder wall has elastic properties and the ability to maintain a constant tension over
a wide range of distension, producing an intrinsic tone in
the bladder wall. As urine enters the bladder, the bladder
wall relaxes, increasing the volume (but not pressure) in
the bladder. The change in volume (dV) in relation to the
change in intravesical pressure (dP) is called the bladder
compliance (dV/dP).
Neural control
To aid urine storage and continence, as the bladder
distends with urine, afferent neural activity from the
stretch receptors in the bladder wall send signals to the
spinal cord initiating the desire to void. The local spinal
cord reflex increases the tone in the striated muscle of
the sphincter, which tightens up thereby promoting
continence. At rest the urethral tone keeps the urethral
walls in apposition to maintain continence. Equally,
voluntary signals from higher centres, can inhibit this
spinal reflex when micturition is desired relaxing the
urethral sphincter.
A decrease in the bladders ability to hold urine may be
due to:
sor muscle
voiding is initiated under brain stem control
end of voiding, the proximal urethra closes in a
retrograde manner
once complete, sacral centres re-inhibit the cerebral
Not at all
<once in 5
<50% of
the time
About 50%
of the time
>50% of
the time
Almost
always
Never
Once
Twice
3 times
4 times
More than
5 times
5
Your
score
Indications from total scores: 07, mildly symptomatic; 819, moderately symptomatic; 2035, severely symptomatic.
Urodynamic techniques
Urodynamics is a term that describes a series of diagnostic tests used to evaluate voiding and storage disorders. Prior to any urodynamics test, a concurrent
urinary tract infection should be excluded as this invalidates any findings of the urodynamics and produces
reversible detrusor instability or incompliance. Most
patients can be assessed adequately using the simpler
urodynamic investigations, but more complex studies are
essential for:
patients with neuropathic disorders
complex cases with equivocal results
apparent failure to respond to previous surgical
procedures.
Simple techniques
Urine flow rate measurements.
Pre- and post-micturition suprapubic transabdominal
ultrasound.
Intravenous urogram1flow rate.
Complex techniques
Cystometry and cystometrography.
Videocystometrography.
imaging.birjournals.org
Overall configuration
Amplitude variations within the flow
Any return to baseline (interruptions)
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Table 2. Normal flow rate measurements
Measure
Male
Bladder capacity
Maximum flow rate
500 ml
Under 40 years .25 ml s21
Over 60 years .15 ml s21
Voiding pressure
4050 cm H2O
Time to maximum flow ,1/3 of total flow time and within 310 s from
start of flow
Female
500 ml
2550 ml s21
3040 cm H2O
,1/3 of total flow time and within 310 s from
start of flow
The shape of the normal flow pattern is unimodal (bell shaped). Flow rate measurements are inaccurate if the voided volume is
less than 125150 ml. Urine flow rate is highly dependent on the volume voided. Flow rates are highest and most predictable
due to optimal detrusor muscle stretch with 200400 ml voided volume. Volumes greater than 500 mls voided volume causes
excessive detrusor stretch with a false reduction in maximal flow rate. The final phase of a normal flow trace shows a rapid fall
from high flow, with a sharp cut-off at the termination.
- Post-void dribble
- Artifacts (e.g. cruising artefact due to patient
voiding at the edge of the funnel or squeezing
artefact secondary to penile squeezing to improve the stream).
A flow test provides the sum of interaction between
detrusor function and outlet resistance, and consequently
cannot determine the cause of voiding dysfunction. For
instance, reduced flow on flowmetry could be either
bladder outflow obstruction or detrusor hypocontractility, whereas supranormal flow may be due to
either detrusor over activity or following reversal of
bladder outlet obstruction.
Ultrasound cystodynamogram
This combines ultrasound of the bladder with flow
rate measurement to provide more detailed information
on bladder function. Ultrasound is an important tool
for assessing bladder wall thickening, trabeculation,
masses, calculi, diverticulae and urinary volumes. A
comfortably full bladder is imaged on ultrasound to
document the full bladder capacity, bladder wall
thickness and bladder wall trabeculation or diverticular
formation. The patient then voids into a flowmeter.
Post-void images of the bladder should be done as soon
as possible after voiding to document true bladder residual
volume. Suprapubic transabdominal ultrasound is well
suited for the measurement of residual volume and has
replaced invasive catherisation for this purpose. In patients
with a significant residual volume, the patient should be
asked to void again and the second post-voided residual
volume documented. There is no evidence-based agreed
specific maximum or a minimum post-void residual
volume that is considered abnormal. An ultrasound
cystodynamogram (USCD) is of particular value in postoperative patients with hypocontractile detrusor dysfunction and after failed repair procedure for stress
incontinence.
Intravenous urodynamogram
This provides upper tract IVU images, includes
a voiding flow rate measured when the patient feels a full
bladder and a subsequent post micturition film which
allows assessment of the residual bladder volume. Intravenous urodynamogram (IVUD) provides a comprehensive assessment of patients with outflow obstruction,
and is particularly useful as it can be integrated into the
routine radiology department without additional equipment or staff training. USCD has almost entirely replaced
IVUD as the latter carries a radiation burden that can be
avoided with ultrasound.
compliance
sensation
stability
capacity.
Videocystometrography
Videocystometrography (VCMG) has gained popularity since its introduction in the 1970s. In this technique the
bladder is filled with contrast medium and the urinary
tract is screened during bladder filling and voiding.
Visualisation of the bladder and bladder neck during
filling, and the urethra during voiding, has added information in integrating various aspects of lower urinary
tract function and characterising abnormalities. Screening
provides additional information on the presence of
vesico-ureteric reflux, level of outflow obstruction in
the lower urinary tract, sphincter competence and
pelvic floor support during straining. Pressure flow
traces are obtained and recorded on videotape,
allowing subsequent review. The normal appearance
of a contrast-filled bladder at maximal distension and
following micturition is shown in Figure 6.
Technique of videocystometrography
In the study, notes are made of initial bladder residual volume, bladder volume at the time of patients
first sensation of filling, final tolerated bladder volume
and final residual volume after voiding. Patients are
asked at the start of the study to void into a flowmeter
to allow assessment of free flow rate. They are then
asked to lie in a supine position on a screening table
while a saline-filled catheter (2 mm diameter) is introduced into the rectum to measure abdominal pressures. The end of the tube is covered to prevent faecal
blockage, but a slit is made in the cover to prevent
tamponade artefacts. A 10 F filling catheter linked to a
1 mm diameter saline-filled pressure catheter is inserted
into the bladder and then disassociated. Alternatively
a 68 F biluminal catheter can be used. The bladder is
drained of urine, providing the measure of resting initial residual volume. The two pressure measurement
lines, bladder and rectal, are zeroed at atmospheric
pressure, connected to the transducers of the
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(a)
(b)
Detrusor overactivity
In normal voiding, the urethra relaxes and the bladder detrusor muscle contracts simultaneously. In dysfunctional voiding, this co-ordination is lost and there is
premature activation of the micturition reflex. This
condition can be further subdivided into detrusorbladder neck dyssynergia and detrusorsphincter dyssynergia. Detrusorbladder neck dyssynergia is also
known as idiopathic detrusor overactivity or detrusor
instability, and is the commonest cause of detrusor
overactivity. It presents in the third decade of life
with a lifelong history of diminished urinary steam.
Detrusorsphincter dyssynergia is also known as neurogenic detrusor hyper-reflexia and is a result of disturbance of nervous control mechanisms. This occurs in
younger women and is often associated with hormonal
disturbances such as SteinLeventhal syndrome, and
rarely complicates neurological disorders such as multiple
sclerosis and Parkinsons disease. In detrusorsphincter
dyssynergia the intravesical pressure is characteristically
unstable, producing intermittent straining and detrusor
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(a)
(b)
Detrusor instability is said to be present if the urodynamics show involuntary phasic detrusor contractions,
producing a rise and fall in detrusor pressure during filling
phase. Previously this was diagnosed only if detrusor
pressure increased by greater than 15 cm H2O during
filling phase. However, the International Continence Society (ICS) Standardisation Steering Committee makes it
clear that any phasic contraction with rise and fall in
pressure is diagnostic of instability. The ICS definition
does not specify a minimum change in pressure, although
waves less than 5 cm H2O are difficult to detect [7].
Detrusor instability seen on urodynamics is not always
clinically significant. Clinically significant instability is one
that produces symptoms of urgency or incontinence.
Detrusor failure
Detrusor failure should be considered in elderly male
patients presenting with incontinence, in whom the
diagnosis may be chronic retention with overflow incontinence. The chronic retention is usually due to
long-standing prostatic obstruction, urethral stricture
or lower motor neurone lesion affecting the bladder.
Urodynamics, particularly cystometry, demonstrates an
underactive detrusor with chronic retention. The detrusor
pressure remains low and unchanging despite increasing
total bladder and abdominal pressure. No significant
(a)
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(b)
Incontinence
Urinary incontinence is defined as the involuntary
leakage of urine through the urethral or an extraurethral route, which can be objectively demonstrated.
Extra-urethral incontinence may be due to ectopic
ureteric insertion, vesico-vaginal fistulae or iatrogenic.
This condition is more common in women and it is
estimated that up to one in four women experience
urinary incontinence at some time in their lives. There
are mainly four types of incontinence:
stress
urge
overflow
unconscious or total incontinence.
Stress incontinence is associated with activities increasing intra-abdominal pressure, such as coughing or
sneezing. In women, descent of the bladder neck and
proximal urethra due to poor pelvic support is the main
cause. In men this is most frequently seen after radical
prostatectomy. The descent of the bladder neck results in
unequal pressure distribution to the bladder, prematurely
elevating the bladder pressure above the urethral
sphincter pressure, resulting in stress incontinence. Surgery remains the mainstay of treatment for stress incontinence. This is sling surgery, either using synthetic
mesh or tissue (cadaveric, stem cell or porcine), which
conceptually tightens the bladder neck. Urge incontinence
is associated with a strong desire to void without elevation
of abdominal pressures, frequency and often with nocturia. This can be a difficult condition to demonstrate and up
to 30% of patients have a normal cystometrogram. Patients
demonstrate an involuntary increase in intravesical pressure (unstable bladder contraction) during bladder filling.
Others have poor bladder compliance, resulting in a small
functional bladder capacity. Conservative urge suppression exercises, timed voiding and medical treatment
with anticholinergic drugs are used to treat urge incontinence. Overflow incontinence is associated with
overdistension of the bladder due to inefficient emptying. This is more common in men and is usually
a complication of bladder outlet obstruction or detrusor
failure. Removal of the cause of bladder outlet obstruction improves overflow incontinence. Unconscious
or total incontinence occurs when the patients first
sensation is wetness without urge or stress. This usually represents at end-stage bladder dysfunction due to
severe sphincter deficiency, bladder instability, overflow
incontinence, or vesico-vaginal or recto-vesical fistulae.
Urodynamic evaluation is important in investigating
all forms of incontinence, but may not be necessary where
history and examination reveal straightforward lower
urinary tract infection or stress incontinence. When primary therapy fails, diagnosis is unclear, or symptoms
and/or signs are complex/severe, more elaborate assessment is generally required, including imaging, endoscopy and urodynamics [810]. The main role of
urodynamic investigations is to identify patients with
imaging.birjournals.org
mixed urge and stress incontinence, large residual bladder volumes, failed surgery or medical treatment, and
evidence of neurological disorders. With VCMG, fluoroscopy during bladder filling may reveal opening of the
bladder neck, descent of the bladder base and leakage in
the supine or standing positions (Figure 12). VCMG
allows differentiation of the relative contributions of
bladder base prolapse and intrinsic sphincter deficiency,
because cystometry defines function, cystography shows
anatomy, and screening demonstrates the dynamics of
the bladder neck, prolapse and demonstrable leakage. In
stress incontinence the bladder pressure should not rise
above baseline during filling, with low voiding pressure
due to reduced outflow resistance. Voiding is rapid and
complete, and cough leakage is almost always demonstrable, and associated with bladder base descent.
Patients are generally unable to interrupt micturition due
to weakness of the voluntary sphincter mechanism.
Complex patients suspected of bladder fistula or urethral
diverticulum will also require cystoscopy.
Detrusor instability is the second commonest cause of
female urinary incontinence and increases with age.
There is an involuntary increase in detrusor pressure,
which causes symptoms of urgency and urge incontinence. Primary detrusor instability is a diagnosis of
exclusion; its aetiology is poorly understood and is defined as instability that is not secondary to outflow obstruction. Secondary detrusor instability may be
associated with Parkinsons disease, spinal cord injury,
diabetic neuropathy, multiple sclerosis, dementia or
stroke; however, most cases have no specific cause.
On urodynamics, there are two main types of detrusor
instability:
phasic
hypocompliant.
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Table 3. Commonest types and causes of incontinence
Incontinence type
Causes
Symptoms
Urge
Stress
Mixed
Overflow
resurgery is contemplated
associated obstructive voiding pattern or abnormal
Conclusion
Simple urodynamic techniques such as flow rate
measurements combined with ultrasound of the bladder
are frequently performed in radiology departments,
largely due to their simplicity, ease of use, affordability
and wide availability. Their interpretation requires the
application of basic bladder anatomy and physiology,
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