Neurourology and Urodynamics 34:640–647 (2015)

International Children’s Continence Society

Standardization Report on Urodynamic Studies of the Lower
Urinary Tract in Children
Stuart B. Bauer,1 Rien J.M. Nijman,2 Beth A. Drzewiecki,3* Ulla Sillen,4 and Piet Hoebeke5
1
Harvard Medical School, Boston Children’s Hospital, Boston, MA
2
Department of Urology and Pediatric Urology, University Medical Centre Groningen, Groningen, the Netherlands
3
Albert Einstein College of Medicine, Montefiore Medical Center, Children’s Hospital at Montefiore, Bronx, NY
4
Department of Pediatrics, University of Gothenberg, Gothenberg, Sweden
5
Ghent University Hospital, Ghent, Belgium

Aims: The objective of this document created by the ICCS standardization subcommittee is to provide a uniform
guideline on measurement, quality control and documentation of urodynamic studies in children. Methods: This
guideline was created using expert opinion and critical review of the published literature on urodynamic studies in
children. Currently no standardized guideline or level 1 data exists on the proper technique for this subject matter.
Results: The document provides a throughout explanation on how to approach a child who presents with lower urinary
tract dysfunction, whether it be of neurogenic, anatomic or functional origin. Formation of an urodynamic question after a
comprehensive history and physical examination is paramount in selecting the urodynamic study(ies) that will be most
appropriate for each child. Appropriate application of each test with careful consideration of the needs of the child and
family will provide the most accurate and reproducible results. Recommendations on how to execute each of the
components of an urodynamic study as well as interpretation are included in the document. Conclusions: Urodynamic
studies have become a major tool in evaluating lower urinary tract dysfunction in children. There are many subtleties in
performing these studies in children in juxtaposition to adults; therefore, adaptations specific to children must be made to
achieve accurate and reproducible results. Uniformity in how the studies are conducted from center to center will allow for
healthier transparency and enhanced comparison of results in both clinical and research situations. Neurourol.
Urodynam. 34:640–647, 2015. # 2015 Wiley Periodicals, Inc.

Key words: incontinence; lower urinary tract; pediatrics; standardization; urodynamics

INTRODUCTION incontinence deserved standardization documents from this

group. A group of 3–5 core experts in each field were appointed
Apart from the ICS report on ‘Good Urodynamic Practices’
to author the document and provide both evidence and
there is no validated guideline on the use of urodynamic studies
experience based knowledge. A complete review of the
(UDS) in children.1 The basics of UDS are similar in both groups,
literature was performed. It was felt that there was not
but pediatric UDS involve different approaches and applica-
sufficient level I or II evidence for a meta-analysis. Therefore,
tions that are unique to this population. The ICCS presents these
recommendations set below are primarily experience based
guidelines for measurement, quality control, and documenta-
with supporting evidence from previously published papers.
tion of UDS in children in both clinical and research environ-
The document was available for review by all members of the
ments. This report describes the most common investigations
ICCS. All critiques were considered prior to submission for peer
performed in children, uroflowmetry, cystometry, and pressure
review.
flow studies. Determination of urethral pressure profilometry
and ambulatory urodynamic testing will be briefly discussed,
as these studies are not widely utilized in pediatrics. Approaching the Child Who Needs Physiologic Evaluation of the
The aim of UDS is to mimic a clinical scenario in a non-clinical LUT
setting while making precise measurements and obtaining
Initially it is imperative to formulate an ‘urodynamic
reproducible results in order to characterize LUT function,
question(s)’ following a comprehensive history, careful physi-
identify the causes for its symptoms, and quantify related
cal examination, and standard urologic investigations. Validat-
pathophysiological processes. Ultimately, UDS should provide
ed questionnaires are helpful in structuring history taking and
(1) objective knowledge about LUT function and dysfunction as
providing checklists for gathering data.2–5
well as (2) an explanation for providers, patients and parents. In
selected populations (e.g., spina bifida), baseline UDS evalua-
tion is paramount as it provides guidance towards manage- Christopher Chapple led the peer-review process as the Associate Editor
ment in addition to noting changes resulting from treatment, responsible for the paper.
Conflicts of interest: none.
growth and/or maturation.

Correspondence to: Beth A. Drzewiecki, Albert Einstein College of Medicine,
Montefiore Medical Center, Children’s Hospital at Montefiore, Bronx, NY.
E-mail: [email protected]
METHODS Received 14 December 2014; Accepted 17 March 2015
Published online 21 May 2015 in Wiley Online Library
The ICCS developed a subcommittee on standardization (wileyonlinelibrary.com).
documents to delineate what fields relating to urinary DOI 10.1002/nau.22783

# 2015 Wiley Periodicals, Inc.

 Standardization of Urodynamic Studies in Children 641
Frequency/Volume Charts: Bladder Diary are instructed to aim their flow at a specific point in the
funnelled receptacle to minimize potential misrepresenta-
The frequency/volume chart (FVC) or bladder diary is a
tions. Afterwards, parents are asked if their child’s flowmetry
detailed recording of fluid intake and urine output over
pattern was representative of their voiding. Maximum flow
specified 24-hour periods. The chart records objective informa-
rate (Qmax) should be sustained for >2 sec to eliminate
tion regarding number of voids, their distribution (day and
artifacts (straining). If the square of Qmax equals or exceeds
night), voided volumes and episodes of urgency, leakage, and/
the voided volume, that value is considered real. Adequate
or frank wetting. For a complete picture of the child’s
voided volumes should 50% of EBC for age, based on the
elimination habits, a 14-day defecation diary that includes
Koff–Hja €lmas equation or that of the MVV measured on the
frequency, soiling and stool consistency based on the Bristol
FVC.15,16
Stool Form scale and Rome III criteria is documented.6
Voided volumes <50% of EBC are not reliable as they may
A properly recorded FVC in combination with repeated (two)
represent forced voiding on command. The bladder scan
uroflowmetries and measurements of post void residual (PVR)
assesses volume beforehand. If not sufficiently full the child
urine volume provides non-invasive, objective information
should be instructed to drink until the bladder is large enough
that help formulate the urodynamic question and determine
for a reliable uroflow.15–17
the need for invasive tests, that is, filling cystometry or pressure
Automated data analysis must be verified and documented
flow studies.
by inspection of the flow curve to exclude artifacts. Results from
Initially, the clinician needs to know the mean bladder
uroflowmetry should be compared with information from the
storage volume during a child’s normal activities. The FVC
patient’s FVC. Sonographic estimation of PVR volume com-
provides the maximal storage capacity as the largest voided
pletes the assessment. In children 6 years, a repetitive PVR of
volume, exclusive of the first morning micturition which
>20 ml or >10% bladder capacity is considered elevated. In
reflects overnight urine production and capacity, and is termed
children 7 years, repetitive PVR > 10ml or 6% bladder capacity
maximum voided volume (MVV).7 MVV should be referenced
is regarded as elevated.18 Ideally 3 uroflows are representative
during cystometry to prevent overfilling. Additionally, it can be
but 2 will suffice as this maintains accuracy and consistency.
used as an outcome measure in children with LUT dysfunction.
First morning uroflows should be avoided as they may exceed
Unsupervised voids in children vary widely due to social
normal voided volumes leading to aberrant flow
circumstances and bladder activity rather than by capacity or
patterns.15,16,19
urine production. Ideally the chart should cover 3 complete
weekdays, but in reality, with difficulties inherent for register-
ing voiding volumes during school hours, it is more suitable for
The Normal Uroflow
weekend recordings. Thus, it is usually restricted to 2 days.8
Voided volumes, even in incontinent children, increase Normal voiding occurs when the bladder outlet relaxes and
incrementally with age. The standard formula for calculating the detrusor contracts. During a normal detrusor contraction
expected bladder capacity is EBC ¼ age (years)  30 þ 30 (ex- with minimal intraurethral resistance, the normal flow curve is
pressed in ml). 9 The FVC is useful when comparing MVV and bell-shaped with a high maximum flow rate. (Fig. 1 A).
standard deviation by a child’s age. Validation and test/retest Abnormal shapes exist that are flat [plateau], asymmetric, or
data on FVCs, while sparse, indicate that voiding interval is the have multiple peaks (fluctuating [staccato] and/or intermittent
most variable parameter.9–11 with >1 complete stoppages of flow [interrupted]). (Fig. 1B, C)
Although suggestive, these patterns do not predict a specific
etiology. A normal flow does not always exclude dysfunction,
FOUR-HOUR VOIDING OBSERVATIONS
nor does an abnormal pattern automatically mean LUT
The four-hour voiding observation provides information dysfunction, as abnormal patterns were found in a small but
concerning voiding patterns, urine volume, bladder capacity definite number of asymptomatic normal school children.20,21 A
and PVR in pre-toilet trained children. Observations are made as minimal number of normal school children void with flattened
children perform activities that are consistent with their daily or intermittent flow curves; most have a bell-shaped curve.22
routine, starting at about 3 months of age. A dry diaper with a Complicated flow rate patterns may result from fluctuations
color-change, vibratory or alarm indicator placed at the outset, in detrusor contractility, abdominal straining, or varying
signals when it is wet. The diaper is weighed (against its dry degrees of outlet resistance. External urethral sphincter or
weight) and sonographic PVR obtained to calculate bladder pelvic floor contraction and relaxation, mechanical compres-
capacity. If no wetness indicator is available the child is checked sion of the urethra or meatal stenosis can cause rapid changes
frequently to accurately assess when voiding occurred so in flow rate.
measurements can be taken. Interrupted voiding is considered Bladder volume may affect uroflowmetry. As the volume
when 2 or 3 voidings occur over a 10-minute interval. This increases and detrusor muscle fibers stretch, increases in
methodology is accurate in both normal children and in those potential detrusor power and work associated with a contrac-
with urologic abnormalities.12–14 tion are needed. This phenomenon is most evident from zero to
150 to 250 ml of filling. At higher volumes the detrusor may be
overstretched decreasing contractility again. Therefore, it is
UROFLOWMETRY
theorized Qmax is physiologically dependent on bladder
Uroflowmetry is an indispensable, first-line non-invasive test volume. Some have questioned this theorem and are working
for most children with suspected LUT dysfunction. Objective, to identify other factors that may be more important in what
quantitative information, which helps to understand both determines Qmax. (I Franco, personal observation). Additionally,
storage and voiding symptoms, is obtainable. rapid changes in flow rate may be artifactual, when the flow
A private bathroom is essential. The child is instructed to rate signal is extracorporeally modified via the interference
void when he/she feels a ‘‘normal’’ desire to urinate. Children between the stream and the collecting funnel, the flowmeter,
who sit to void should have a footrest supporting their feet to patient movements or changes in aim of the stream; thus,
eliminate the possibility of a non-relaxed pelvic floor. Boys proper positioning and instruction are necessary.

Neurourology and Urodynamics DOI 10.1002/nau

642 Bauer et al.

Fig. 1. A: Normal (bell shaped) urinary flow curves of 2 children. B: Flow curves of 2 children with a static, anatomic obstruction; the curve is continuous but
the flow is lower than normal and extended in time. C: Interrupted flow curve in a child with either discoordination between bladder and contraction and
sphincter relaxation (pelvic floor muscles) or underactive bladder with abdominal straining to empty.

Decreased detrusor power and/or consistently high urethral Problems in Urine Flow Rate Measurement
resistance will result in both a lower flow rate and a smooth
flat flow curve. A constriction (e.g., urethral stricture), with The shape of the flow curve may suggest an abnormality, but
reduced luminal size produces a plateau like flow curve reliable and specific information about its cause cannot be derived
(Fig. 1B). solely from the pattern. Only when combined with pelvic floor
The same parameters used to characterize a continuous electromyography (EMG), intravesical and abdominal pressure
flow should be applied to children with interrupted, or recordings, the pressure-flow relationship, does it become possible
staccato patterns (Fig. 1C). When measuring flow time, the to analyze the separate contributions of the detrusor and bladder
intervals between flow episodes are disregarded. Voiding outlet to the overall voiding pattern. Uroflowmetry without EMG
time is the total duration of micturition, including is discouraged unless it is done for follow-up situations where only
interruptions. the actual curve and residual urine are needed.

Neurourology and Urodynamics DOI 10.1002/nau

 Standardization of Urodynamic Studies in Children 643
Dual channel EMG with perineal AND abdominal EMG helps dysfunction (children with dilating VUR and recurrent febrile
define if patients have abdominal straining that results in a UTI), or significant PVR of unknown cause.
spike in Qmax or changes in the shape of the curve from plateau
to other forms. EMG lag time, or time between pelvic floor
Cystometry and (Video)-Urodynamics
relaxation and the start of flow, has predictability for
characterization of bladder dynamics (see below). Intravesical pressure-volume relationships are measured
during cystometry. Information is gleaned on storage function
(detrusor activity, sensation, compliance, and capacity) and
Recommendations for Uroflowmetry
voiding function (outflow obstruction, flow pattern, detrusor
To facilitate recording urinary flow rate characteristics and contractility and sustainability). Abdominal pressure record-
pattern recognition of curves, graphic scaling must be standard- ings via a small rectal balloon catheter are necessary to
ized: one millimeter ¼ 1 sec on the x-axis and 1 ml/s and 10 ml accurately assess changes in abdominal pressure as reflected in
voided volume on the y-axis. For routine clinical measurements intravesical pressure changes. To evaluate voiding function, the
it is useful to read flow rate values to the nearest full ml/s and patient should be in a sitting position. Children who are not yet
volumes to the nearest 10 ml. To have electronic Qmax values that toilet trained or unable to support themselves sitting upright,
are reliable, internal electronic smoothing of the curve by may lay supine for the voiding phase, thus excluding recording
removing positive and negative spike artifacts should be applied. accurate flow rate data. (Fig. 2)
Interpretation of any dynamic variation (signal patterns) in In newborns, only storage function can be evaluated. Voiding
free flow relies on personal experience, can be only descriptive, may be observed, but reliable pressure-flow studies are difficult
and often remains speculative. to perform.
Uroflowmetry combined with pelvic floor patch EMG differ- Cystometry in conjunction with fluoroscopy (video-urody-
entiates an interrupted or staccato flow secondary to a non- or namics) records fluoroscopic images during testing that have
intermittently relaxing external sphincter from straining several advantages. The shape of the bladder and bladder neck
maneuvers to empty. When free uroflowmetry reveals these during filling and voiding, appearance of the urethra during
patterns a flow—patch EMG is warranted.23 voiding, the volume and pressure when VUR occurs, and the
influence of voiding on VUR can be objectively noted. These are
vital in neuropathic bladder dysfunction, where this informa-
Invasive UDS
tion, unobtainable otherwise, can lead to possible causes for
In children UDS should be performed if the outcome is likely incontinence and/or reflux as noted by poor pelvic floor
to affect treatment or when treatment does not lead to its relaxation, urethral overactivity and/or elevated residual urine.
intended outcome.24,25 Testing is considered when surgical Cystometry combined with nuclear cystography precisely
interventions are planned. Invasive UDS provides information identifies when reflux occurs during cystometrography (vol-
not readily available elsewhere and which influences further ume and pressure) as the camera continuously records gamma
management. From studies addressing this issue in children radiation location of the nucleotide without increased radiation
with LUTS but without neuropathy, invasive UDS rarely exposure, but it does not provide absolute anatomic detail.
provides significant additional information to justify its Because UDS is an invasive procedure artifacts may influence
use.26–28 Baseline UDS in children with neurogenic bladder accurate interpretation of results.30 Despite all efforts to achieve
may not influence immediate management but when there is a normalcy, the test environment is not natural; most children are
change in continence, recurrent UTIs or new/worsening apprehensive to a degree that can influence findings; a
hydroureter or hydronephrosis, it can be used as comparison transurethral catheter may affect voiding; and catheter ‘irrita-
for subsequent testing. tion’ may induce detrusor overactivity. Suprapubic catheteriza-
Indications for invasive UDS in non-neurogenic conditions tion may eliminate voiding abnormalities associated with a
include: voiding frequency 3 per day, straining or manual urethral catheter but detrusor overactivity may result despite a
expression during voiding, a weak urinary stream, urge latency period for accommodation from insertion to testing.
incontinence unresponsive to proper elimination habits or Cystometry performed using the body’s natural diuresis to
pharmacotherapy, pronounced apparent stress incontinence, fill the bladder (natural fill cystometry or ambulatory urody-
or new or worsening dilating vesicoureteral reflux (VUR, namics) is time-consuming and not practical in most centers.
grade 3 reflux, international classification). In children with When performed, the child is permitted to be mobile,
neurogenic bladders, investigation is warranted when recur- compatible with his/her own surroundings, that theoretically
rent febrile UTI occurs where previously identified or newly produces less psychological stresses. Natural fill studies
diagnosed VUR may indicate a deteriorating bladder. In centers elucidate lower voided volumes, higher voiding pressures, a
where voiding cystourethrography is performed separate from dampened increase in the pressure rise during filling and
invasive UDS, an abnormal appearance to the bladder contour increased sensitivity for detecting detrusor overactivity.31
suggesting a neurogenic cause in an otherwise neurologically To reduce anxiety, the study is best performed with the child
intact child, with or without VUR, should prompt these studies. seated, watching a video or DVD accompanied by one or both
In children with neurogenic bladder dysfunction, the ICCS parents. Only essential equipment should remain in the room.
has recommended an initial evaluation and subsequent studies Avoiding general anesthesia is important as this affects the
as follows:29 in the first 2 to 3 months of life, in response to natural state and eliminates the chance for voiding. Intranasal
therapy, development of hydroureteronephrosis, a change in midazolam may be administered in certain situations where
continence or a question of progressive spinal cord tethering high anxiety levels cannot be mollified, as this drug appears to
when concomitant signs are evident. be innocuous regarding outcome of the study.32
In summary, invasive UDS are indicated when non-invasive Both the child and his/her parents need adequate prepara-
investigation raises suspicion of neuropathic detrusor-sphincter tion about every aspect of the study before it is undertaken. If
dysfunction (occult spinal dysraphism), obstruction (i.e., posterior the initial investigation is inconclusive and/or inconsistent
urethral valves), genitourinary abnormalities (i.e., exstrophy, with the history or prior uroflowmetry, repeating it 2 to 3 times
epispadias), profound non-neuropathic detrusor-sphincter may be necessary.33,34

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644 Bauer et al.

Fig. 2. UOS illustrating involuntary detrusor contractions (DO), counter action of pelvic floor muscles (guarding reflex) and incomplete relaxation during
voiding results in higher than normal voiding pressures and substantial post-void urine volume (DO þ dysfunctional voiding).

Most children readily accept a 6- or 7- Fr. double lumen A small (8-Fr) rectal balloon catheter is inserted to record
transurethral catheter to fill the bladder and record pressure. In abdominal pressure changes that are then subtracted from
selected cases, a suprapubic catheter may be inserted under bladder pressure channel recordings to obtain true detrusor
general anesthesia the previous day or several hours earlier on pressure. This reduces artifacts of movement and helps denote
the same day, but risks need to be juxtaposed against benefits straining to void from normal relaxed voiding. A suppository or
of this approach. It has been shown transurethral catheters (6 or enema is recommended the evening before the study to cleanse
7 Fr.) do not significantly obstruct the urethra.35,36 the rectum and increase accuracy of rectal pressure recordings.
Before inserting a catheter, a uroflow is obtained (the child A microtip transducer catheter may be as small as 3-Fr, but
is instructed to arrive with a full bladder). After voiding is passage of this sized catheter is not easy in boys. Although once
completed, a transurethral catheter is inserted in a timely popular, it has been abandoned in most pediatric centers.
manner and residual urine measured and cultured. If When video-urodynamics are performed images are taken at
infection is strongly suspected (this sample is cloudy, 30 or 50-ml intervals of filling, during any findings of increased
odorous, and/or has positive nitrites on analysis) the test pressure, when reflux is detected, at capacity and during
should be delayed until a sterile urine is obtained. For voiding. X-ray memory features limit exposure time, currently
children on CIC, colonization is common so a culture and averaging 0.45 min, making the total amount of radiation less
appropriate antibiotics beginning 3 days prior to the study is than that of a plain abdominal radiograph.
preferable. To study pelvic floor muscles reactivity, surface electrodes are
When the residual is substantial, recording the intravesical widely used. The EMG pads are positioned symmetrically,
pressure before draining the bladder provides a simple one- perineally, left and right of the anus. Due to resistance of
time measurement that can be compared to the pressure electrical current across skin—electrode interface—the skin is
recorded when the bladder is filled to that specific volume degreased (alcohol) and exfoliated (fine abrasive paper) before
during cystometrography, to determine if even relatively applying conductive gel and electrodes patches. In cases of
slow but unphysiologic filling rates affect detrusor known or suspected neuropathic bladder, external urethral
compliance.37 sphincter needle EMG assessing of individual motor unit action

Neurourology and Urodynamics DOI 10.1002/nau

 Standardization of Urodynamic Studies in Children 645
potentials is extremely valuable in detecting early or progres- In children without neuropathic lesions, compliance should not
sive signs of denervation, especially in children with suspected exceed a 0.05 y ml/cm H2O increase from baseline bladder
tethered spinal cord syndromes.38,39 pressure (y ¼ cystometric bladder capacity [ml]) for age), a formula
In children, the transition from filling to voiding is not as developed for adults but one that is not fully applicable to children
easily managed as in adults. To avoid missing this important because bladder capacity increases with advancing age, and that
transition, cystometry and pressure-flow/EMG measurements must be accounted for as well. There is no reported relationship
are performed as one continuous study. between expected and cystometric bladder capacity; however,
With retrograde filling via a catheter, 0.9% saline or contrast some feel Pdet should not exceed 30 cm H2O at EBC.41
medium warmed to body temperature (37.58C) is infused. In Detrusor activity is interpreted from measuring Pdet. During
infants, temperature of the infusate may influence bladder capacity the storage phase it may be normal, overactive, or underactive.15,16
and detrusor activity; however, its clinical relevance remains In normal children, a minimal rise in detrusor pressure occurs
unknown.34 throughout filling. This process is called accommodation. Even
When filling by catheter, slow fill cystometry (5–10 percent of after provocation, there should be no involuntary contractions.
EBC per minute, or <10 ml/min) is recommended, as compli- The normal detrusor is described as stable.
ance (predominantly) and overactivity (possibly) may be Involuntary detrusor contractions during filling (spontane-
significantly altered by faster rates of filling.40 ous or provoked) are characteristic of ‘‘detrusor overactivi-
ty’’.15,16 (Fig. 3) The child may not completely suppress these
contractions; usually, an increase in pelvic floor EMG activity is
Assessment of the Storage Phase
noted as a counteractive guarding reflex.43 Involuntary
Parameters measured during the storage phase include: detrusor contractions may also be provoked by alterations in
intravesical pressure (Pves), abdominal pressure (Pabd) and posture, coughing, laughing, walking, jumping, suprapubic
detrusor pressure (Pdet). Pdet ¼ Pabd () Pves. tapping or compression and other triggering stimulants. The
In cases of sphincter incompetence or lack of bladder presence of these contractions does not necessarily imply a
sensation, maximum cystometric capacity is difficult to neuropathic disorder. In infants, detrusor contractions may
determine. A Foley balloon catheter can occlude the bladder occur in 10% of normal children during filling. Occasionally,
outlet to determine capacity and measure compliance. Presence overactive contractions may be seen very near capacity, which
of a sensory lesion warrants stopping filling when resting
detrusor pressure reaches (exceeds) 30 cm H2O.41
Bladder sensation is very difficult to evaluate: it may be a
relevant parameter only in toilet-trained children. Terminology
like ‘‘first desire to void,‘‘ and ‘‘strong desire to void,‘‘ although
useful in adults, have little value in children. Normal desire to void
is not relevant in infants, but can be a guide in toilet trained
children 4 years. Normal desire to void should be considered as
the volume at which some unrest is noted, that is, wiggling of toes
usually indicates voiding is imminent. In the older child when fear
of discomfort may result in smaller than expected volumes during
initial cystometrography, or when DO is anticipated but not seen,
2 cycles of filling are recommended (personal observation).
Bladder sensation can be classified as normal, increased (hyper-
sensitive), reduced (hyposensitive), or absent.
Compliance indicates the change in volume for a change in
pressure and is calculated by dividing the volume change (DV)
by the change in detrusor pressure (DPdet) during a specific
increase in bladder volume (DV/DPdet). It is expressed as ml
per cm H2O. When abundant detrusor overactivity is present, it
may be difficult to determine compliance. To standardize the
measurement, the most linear part of the V/P relationship
should be isolated used for calculating compliance. The values
for V and P at the beginning and end of this portion of the
tracing are then used to calculate DV/DPdet. The usual notation
for compliance is a single value, but a full characterization of
compliance may be helpful, as some children have varying
compliance factors throughout filling.42
This variability depends on several factors: rate of filling,
which part of the curve is used for compliance calculation,
shape (configuration) of the bladder, thickness, and mechanical
properties of the bladder wall, contractility, relaxability of the
detrusor, and degree of bladder outlet resistance.33
When little or no pressure change is noted during filling,
compliance is called normal. There are no data available to
exactly determine normal, high or low compliance values.
When reporting compliance the rate of bladder filling, the
volumes in between when compliance is calculated, and Fig. 3. Improper position for voiding: the feet are not supported (unbalanced
which part of the curve used to derive this number should be position) and the boy is bent forward. Support of the feet will correct this
noted. allowing the pelvic floor muscles to relax property.

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646 Bauer et al.
should be interpreted as normal. In children with VUR, detrusor function may be due to overactivity of the sphincteric
overactivity is seen in more than half the infants.44–47 mechanism or anatomical obstruction (posterior urethral
Overactivity due to a disturbance of the nervous system is valves, urethral stricture, ectopic ureterocele).
called neuropathic detrusor overactivity. In the absence of any An anatomic obstruction is a fixed narrow diameter in a
neuropathology, it is called idiopathic detrusor overactivity. urethral segment that does not expand during voiding, resulting
Any leakage occurring during an involuntary detrusor contrac- in a plateau shaped flow pattern, with a low and constant
tion is labelled detrusor overactive incontinence.15,16 maximum flow, despite high detrusor pressure and complete
If an underpowered or no detrusor contraction is seen at the relaxation of the external urethral sphincter (EUS). Functional
end of filling (when filling reaches 150% of MVV), the detrusor is obstruction, is the active contraction of the EUS during voiding
underactive. This is an arbitrary percentage agreed to by the that creates a narrowed urethral segment, either constantly or
ICCS terminology standardization committee based on MVV; it intermittently. Functional and anatomic obstructions can be
is variable for each child. When the child has the ability to differentiated by measuring EUS activity during voiding with
completely suppress voiding for fear of discomfort with the simultaneous recordings of pressure and flow (urethral resis-
catheter in place this may be normal but it may lead to tance at the EUS), or EMG activity of the striated EUS, using
overfilling during the study. Despite encouragement, the needle or patch electrodes. Video UDS is helpful, as pelvic floor
catheter may need to be removed to allow the child to urinate. muscle activity can be observed during voiding, as well as
The study is interpreted as normal detrusor function, especially differentiating anatomic from functional obstruction.51
if the child then empties. True detrusor underactivity may result In some children fearful of voiding, ‘‘urethral overactivity’’
from chronic bladder outlet obstruction or a neuropathic lesion may be a natural reaction resulting in elevated voiding
leading to impairment of emptying.15,16 pressures, intermittent voiding and/or substantial PVR. In-
The normal urethral closing mechanism maintains a positive creased activity occurs as the child senses the need to urinate. In
urethral closure pressure (guarding reflex).43 Shortly before neuropathically induced detrusor-sphincter dyssynergia, the
micturition, the normal closure pressure decreases to allow for detrusor contraction and involuntary contraction of the
flow. An incompetent closure mechanism is defined as one that urethral and/or periurethral striated muscles occur simulta-
allows leakage of urine in the absence of a detrusor contraction. neously during micturition. When overactivity of the EUS
In genuine stress incontinence, leakage occurs when Pves occurs during voiding in neurologically normal children, it is
exceeds Purethra (intraurethral resistance) as a result of an termed dysfunctional or discoordinated voiding.,15,16,45,52
increase in intraabdominal pressure, often in conjunction with Investigators have looked at the time differential between
low Purethra.43 Although common in multiparous females, it is relaxation of the EUS (as measured by patch perineal electrodes) and
exceedingly rare in pediatrics but may be noted in athletically the opening of the bladder neck on video-urodynamics, calculating
active teenage girls.48 the normal time difference as 2 sec. This is labelled ‘‘lag time’’. It may
To clinically define a bladder with high pressure at normal be calculated from pressure flow studies that include perineal EMG
capacity, the term detrusor leak-point pressure has been when not employing videourodynamics. When shortened (2 sec)
introduced. It is measured by subtracting Pabd from Pves at it is considered a sign of detrusor overactivity, when prolonged,
the moment of leakage when the first drops of urine pass >6 sec, an indication of bladder neck dysfunction.53
through the meatus in the absence of raised abdominal pressure
or an involuntary detrusor contraction. A pressure <40 cm H2O is
CLINICAL IMPLICATIONS
considered acceptable for those with a fixed urethral resistance
who cannot generate a detrusor contraction.49 It cannot be overemphasized that invasive UDS should be
conducted only if a treatment strategy has been outlined
beforehand. Without such an indication, a study should not be
Assessment of the Voiding Phase
undertaken.
During voiding the detrusor may be classified as normal, UDS in children are best performed under the auspices of a
underactive, or acontractile. knowledgeable urologist or trained urodynamacist. In order to
Normal voiding is achieved by a voluntarily initiated detrusor obtain a complete picture of LUT function, presence and
contraction; it is sustained and cannot be suppressed easily once observation by these professionals during the investigation,
it has begun. In the absence of bladder outlet obstruction, a seeing how the child behaves during testing and monitoring
normal contraction will lead to complete emptying. patient and parent interactions throughout the study are
In children with normal neurologic function, when standard fill paramount. Family dynamics and what role they might play in
cystometry was performed the mean detrusor pressure during etiology and persistence of the dysfunction, as well as what
voiding was 127 cm H2O in boys and 72 cm H2O in girls at a treatment strategies might be appropriate can be acertained.
median of 1 month of age; this exceeds adult values, consider- UDS are invasive, the surroundings frightening, and the whole
ably.50 These pressures vary somewhat from those reported by procedure unnatural for the child. Some children will only void
Yeung, as he found infant boys have pressures of 118 cm H2O and when everyone has temporarily left the room. Availability of a
girls of 75 cm H2O when these measurements were taken during television, videotape recorder or DVD player provides a major
natural fill cystometry.4,45 The acontractile detrusor demonstrates diversionary advantage in assuaging anxiety and creating a
no activity during voiding. If acontractility is neurologically distraction during the procedure. In very small children,
induced, it is called detrusor areflexia. It denotes the complete parents are advised to bring a bottle and/or favourite toys.
absence of a centrally coordinated contraction. Terms such as
hypotonic, autonomic, or flaccid are to be avoided.15,16
CONCLUSION
If a detrusor contraction is inadequate in magnitude and
duration to effectively empty the bladder, it is referred to as Urodynamic investigation has become a major tool in the
detrusor underactivity during voiding.15,16 The urethra during evaluation of LUT dysfunction in many children; however, it is
voiding may be normal or obstructive. The urethra opens during invasive, time and resource consuming and far from natural. Thus,
voiding to allow the bladder to empty at normal pressures artifacts may affect to a great extent correct interpretations.
without any loss of kinetic energy. Obstructive urethral Despite best intentions, these investigations may not always yield

Neurourology and Urodynamics DOI 10.1002/nau

 Standardization of Urodynamic Studies in Children 647
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ACKNOWLEDGEMENTS 23. Hoebeke P, Bower W, Combs A, et al. Diagnostic evaluation of children with
daytime incontinence. J Urol . 2010;183:699–703.
We would like to thank Tryggve Neveus for his instrumental 24. Szabo L, Lombay B, Borbas E, et al. Videourodynamics in the diagnosis of
contributions to this document from organizing the group, urinary tract abnormalities in a single center. Pediatr Nephrol. 2004;19:
persitently encouraging its development and critical reviews. 326–31.
25. Bauer SB. Pediatric urodynamics: Lower tract. In: InO‘Donnell B, Koff SA,
editors. Pediatric urology. Oxford: Butterworth-Heineman; 1998. 125–51.
AUTHOR CONTRIBUTION 26. Kaufman MR, DeMarco RT, Pope IV JC, et al. High yield of urodynamics
performed for refractory nonneurogenic dysfunctional voiding in the
S.B.B.: Manuscript design, concept and content, with final pediatric population. J Urol . 2006;176:1835–37.
approval. R.N.: Manuscript design, concept and content. B.A.D.: 27. Soygur T, Arikan N, Tokatli Z, et al. The role of video-urodynamic studies in
Critical review, manuscript content and construction of managing nonneurogenic voiding dysfunction in children. BJU Int.
2004;93:841–843.
document. U.S., P.H.: Manuscript design, concept and content, 28. Hoebeke P, Van Laecke E, Van Camp C, et al. One thousand video-urodynamic
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Neurourology and Urodynamics DOI 10.1002/nau