Urodynamics (UDS) Special Interest Group (SIG) - Trouble Shooting UDS
At the last few SUNA Symposium’s, attendees were ask to complete a UDS SIG Survey. The survey sought solutions to problematic issues encountered performing UDS testing. Following are answers to some of the survey questions. DISCLAIMER: These answers only reflect my view and experience only and not that of SUNA. Additionally, I have attempted to match up several of you with mentors, as requested. Feel free to contact me if you have any questions about UDS or you would like to fill out a UDS SIG Survey. The discussions Board on the SUNA website for the Special Interest Groups are no longer being utilized. You may contact me at firstname.lastname@example.org or select “email us” on the SUNA website with any UDS questions or comments.
Trouble Shooting Questions
1. Question – What is Artifact? There are several types of artifact when it comes to UDS. Here are just a few.
a. Patient kicked the Uroflow cup during the test? If the Uroflow is salvageable, move the Uroflow markers to measure the urine not the spike that is artifact. If not salvageable, obtain a mechanical fill at the end of your CMG study. Fill up your patient’s bladder again on “Fast Fill” at the end of the study to the amount filled up on the CMG portion of the study. Ask the patient if they have a strong urge to void, then remove the Pves catheter and allow the pt to void after changing the screen to the ,“Non Instrumented Uroflow Test”, on your software and give the patient “Permission to void”.
b. Patient passed gas during my CMG study and the Pabd channel went up? Yes, this happens sometimes. Document the event and add a comment on rise of Pabd, “Patient passed gas”.
c. Pves catheter fell out? To avoid this in female patients, insert the Pves catheter to 20cm at least and tape the catheter onto the outer labia and the inner thigh of the patient. Be sure Pves and Pabd tubing/extension are out of the way when the patient voids.
For Male patients: Insert the Pves catheter the length of penis plus 2 inches. Apply a thin strip of tape on the shaft of penis and run the tape down the Pves catheter and secure well by folding the tape in half.
d. What is "Saw tooth effect"? Your fill line tubing is lying or touching the Pves or Pabd tubing. It makes the channel being affected look like a wavy line. Simply move the fill line off the tubing being affected and that channel line will smooth out.
Remember! UDS is like telling a story to someone (physician reading tracings) who is not usually present. You want to present a clean study with documented events that tell the story of the patient’s symptoms you are attempting to demonstrate. You want to document what happened during the filling and the voiding phase of the study. You are trying your best to reproduce symptoms but sometimes it is not achieved in spite of your best efforts.
e. EMG channel is not monitoring correctly. I would have the patient move a few inches forward if sitting down. Sometimes when they sit on the seat the EMG patches reflect a solid red line with no recruitment detected when the patient is asked to cough or squeeze. You should always have your patient cough at the beginning of each study to ensure all channels are responding appropriately. Apply tape over EMG patches if female patient so when she voids, the EMG patches do not get wet. This is usually not an issue for males. Add a note on report if EMG patches get wet (artifact) and if EMG was active or quite during voiding (synergistic/dyssynergia).
2. I do not understand zeroing to atmosphere vs. to the patient. What is the difference? International Continence Society (ICS) recommends zeroing to atmosphere, not the patient. This means that your baseline will start at the patient’s actual resting pressures before you start filling up your patient’s bladder. When you zero to the patient, which is not recommended by the ICS, you are taking the patient's resting pressures (Pves/Pabd) being measured by the catheters and zeroing that number so their resting pressure has been manipulated. Zeroing to atmosphere may be done with Water-filled and Air-Charged catheters. If you need more details on how to do this please feel free to email me.
3. What do you do if channels’ (Pves/Pabd) drift during the filing phase and voiding phase of the CMG? The answer to this is that it depends. If I am filling up my patient’s bladder and the Pabd channel starts to drift, I observe it for 1 min. or so before I start to troubleshoot. Usually, it will drift right back up. I think the most important thing to remember when starting out is to begin with zeroing to atmosphere first, as recommended by the ICS. Make sure the Pves channel (bladder pressure) and the Pabd channel (rectum pressure) do not allow the actual bladder pressure measured by the Pdet channel to go below -5 or above + 5 during the filling phase. The Pves channel will rise slowly during the filling phase and this is where you would monitor compliance. Mark any artifacts. This could mean that the Pabd catheter in the rectum is picking up the peristalsis movement in the rectum where the Pabd catheter is sitting. It is not recommended to use the = button during the filling phase of the study as this is artificially correcting the pressure vs. stopping the study and troubleshooting the problem. The equal button was intended to balance the Pabd pressure at the beginning of the study when off by 1-2 cm H20 after all trouble shooting efforts are exhausted. During the voiding phase, the Pabd channel will drift down.
4. Early sensation due to cool water being used to infuse into bladder? Recognize that this is what most patients will feel during the start of the filling phase of the study. Tell your patient that if they feel a cool sensation of water going into the bladder that this is normal. Then, ask the patient to identify when they feel that first sensation that their bladder is getting full. Then have them identify when they feel a strong urge (for example, you are in a really long line at a movie ticket counter and have to go to the bathroom) and lastly, have them identify when they cannot take any more and need to void or become incontinent.
TIP: Explain to the patient when it is time to void, they need to relax and be still so that the pressure being generated in their bladder during voiding is measured correctly. Remind them not to talk, push or move during this phase. I always play classical, jazz, or contemporary music during procedures and my patients always comment how much they enjoy it and that it relaxes them.
Thanks to everyone who completed the surveys.
Myra Joseph RN
UDS SIG Leader
Insights to Men’s Health
Here at Alamo SUNA each of our members are now making short contributions to the webb site on topics that we enjoy and are professionally involved in. Being a male in a female dominated profession, practicing in urology for over a decade and approaching my sixth decade of life I have considerable interest in “Men’s Health.”
Urologically speaking “men’s health” generally refers to erectile function, in which we utilize any number of medications, devices and implants to allow men to achieve an erection firm enough for penetration and sexual satisfaction.
After 35 years of practicing nursing in predominantly military facilities, I have worked with men in nearly every physical state imaginable. From the Special Forces conditioned to the patient in hospice care, men have holistic needs that are generally not met in most health care systems. Most major health care systems have “Women’s Health” clinics and are generally intergraded with GYN, however how many “Men’s Health” clinics do we see?, Men do not see urologists for routine well care.
I would argue that men’s health lacks the type of clinical focus of women’s health and men’s health does not have the equivalent of the gynecologist. The specialty of Andrology or the “science of men” has only been a distinct specialty since the late 1960’s and is primarily focused on reproductive problems that are unique to men. While studying Enterostomal Therapy at M.D. Anderson Cancer Center in the early 90’s, one of the primary nursing principles taught was “eliminate or reduce causative factors”.
So what are the causative factors of ED? We are now coming to understand that ED is not a benign localized condition to the male genitalia but a systemic disorder. ED can be a symptom of early “metabolic syndrome” involving a number of risk factors, some modifiable, some not. This paper will briefly discuss modifiable risk factors and techniques to mitigate the sequela of non-modifiable risk factors. It has been my experience that a significant portion of men’s health issues stem from the following modifiable risk factors; cigarette smoking, sedentary lifestyle, atherogenic diet, poor management of stress/anxiety/depression and possibly hypogonadism.
The horrifying effects of nicotine addiction have been so thoroughly documented for decades, elaboration of the systemic damage done to every organ in the human body is hardly necessary for this discussion. If a person is seriously interested in living a longer, healthier life, smoking cessation needs to be your number one priority. Even if you no have no desire to quit, consider the second hand impact of smoking on your loved ones around you.
Hand in hand with sedentary lifestyle is the epidemic of obesity. Among men, visceral fat is the most detrimental. Belly fat or abdominal circumference is a key indicator of "metabolic syndrome," a cluster of abnormalities that include high levels of blood sugar, blood pressure, and triglycerides, as well as low levels of "good" HDL cholesterol. Therefore it is appropriate to think of belly fat as a endocrine gland because it is very metabolically active. It releases fatty acids, inflammatory agents and hormones that ultimately lead to higher LDL cholesterol, triglycerides, blood glucose and blood pressure. In addition, belly fat contains aromatase, an enzyme that converts the male hormone testosterone into the female hormone estrogen. A study performed by the British Nutrition Foundation found that by keeping your waist circumference to less than half your height, the potential for stroke, heart attack and diabetes is reduced.
We have all seen diet fads come and go, however there are a number of foods that should be eliminated from your diet to reduce abdominal circumference and high levels of blood sugar. Drinking soda is like drinking liquid candy. Without question, sodas are calorie bombs that have contributed to the obesity epidemic in our country; soda has also been linked to an increased risk of certain cancers, premature aging and hormone disruption. Added sugar, in all its forms, hidden in almost all processed foods has also contributed to the obesity epidemic in this country. It is estimated that 50% of all Americans consume one-half a pound of sugar every day, or 180 pounds of sugar per year, most of it in the form of fructose which is derived from corn syrup. Fructose creates a metabolic disaster in your body, elevating uric acid, generating low level inflammation which leads to strokes, some cancers and premature aging. It is recommended that you eat meals with natural sugars (Fruits), a source of protein and a minimally processed carbohydrate. Chips or cancer in a bag are not even potatoes. They are slurry of genetically engineered rice, wheat, corn, and potato flakes that are pressed into shape. A byproduct of this process is Acrylamide, a cancer-causing and potentially neurotoxic chemical, is created when carbohydrate-rich foods are cooked at high temperatures, this goes for French fries too. Other dietary nightmares include fried farm raised seafood, doughnuts, processed meat and microwave popcorn.
Arguably one of the best methods for a man to maintain weight and overall physical health is weight training. The benefits of working with weights is that it is safe for all ages, increases bone density, improves balance, boosts metabolism, improves sleep and reduces symptoms of arthritis, diabetes and other chronic conditions. Whether you use free weights, resistance bands, body weight or any other method, a little weight training can provide significant benefits even for those who are not in perfect health. One study on older adults (Campbell, 1994) showed that a 3-month basic strength-training program resulted in the exercisers adding 3 pounds of muscle and losing 4 pounds of fat, while eating 15% more calories!
Another benefit of weight training is improved mental and emotional health. Studies have shown that people who exercise regularly sleep better; they sleep more deeply and longer and awaken less often. In addition weight training can reduce depression and boost self-confidence and self-esteem and improve your sense of well-being.
Management of stress/anxiety/depression and enhancement of emotional health is critical to a man’s “whole”. Patients who have survived war and cancer and then manage to maintain good emotional health all seem to have several things in common. They are in a healthy, stable relationship in which they can talk through feelings, have come to accept each other for who they are and support one another during trying times. Emotionally healthy men who are survivors, also seem to see a bigger picture, i.e. “yes I leak, but I’m not dying of cancer”. In addition these men also take time to enjoy; they are involved with groups, church, community, travel or doing something creative. This involvement takes their minds off of worries, connects them with others and provides a sense of belonging.
As mentioned earlier, getting plenty of sleep is vital to overall health, not getting enough sleep can make you feel tired, worn out and run down. It can also make you more prone to physical and mental health problems. Set a sleeping schedule and stick to it every day, even on weekends, holidays and days off. Being consistent reinforces your body's sleep-wake cycle and helps promote better sleep at night. Don't go to bed either hungry or stuffed. Limit how much you drink before bed, to prevent disruptive middle-of-the-night trips to the toilet. Get comfortable and create a room that's ideal for sleeping. Often, this means cool, dark and quiet. Consider using room-darkening shades, earplugs, a fan or other devices to create an environment that suits your needs. Your mattress and pillow can contribute to better sleep, too. Since the features of good bedding are subjective, choose what feels most comfortable to you. If you share your bed, make sure there's enough room for two. If you have children or pets, try to set limits on how often they sleep with you.
In this day and age stress is a fact of life, but being stressed out is not. It’s a fact that the more a man is stressed out the more prone we are to chronic and acute illnesses, and the less open we are to the pleasures and beauty that surrounds us. Approaches to stress and anxiety reduction can begin with setting limits; just say no to demands to please everyone all the time. Another approach is evaluating your response to a situation; is it absolutely critical? Are your stressors exaggerated?, and avoid fixating on the “what if’s”. Understand that although stress and anxiety are uncomfortable feelings, these negative feelings will pass. Ironically, accepting that you are feeling anxious and stressed out helps activate the body's natural relaxation response.
The last item on our list of modifiable risk factors is hypogonadism, a condition characterized by low serum levels of testosterone in association with specific signs and symptoms. “Low T’” is commonly associated with sexual symptoms such as decreased libido, ED, difficulty achieving orgasm and decreased performance. However hypogonadism also impacts cognition, mood, energy and vitality. The physical effects of hypogonadism are also profound on a man’s health; decreasing muscle mass, bone density along with increasing body fat, infirmity and fatigue. Other effects of hypogonadism continue to be researched, the correlation of hypogonadism with prostate cancer and testosterone as a modulator of vascular function. Testosterone replacement therapy can be done topically or with injections with the goal of stabilizing symptoms. Replacement therapy has few contraindications, heart failure, sleep apnea and severe benign prostatic hypertrophy. Interestingly enough, an article in the April 2014 edition of Urology Times News describes a small study that suggests that testosterone replacement does not appear to increase the risk of prostate cancer. In addition 30 of the 76 men who were hypogonadal had prostate cancer, implying that hypogonadism offers no protection from prostate cancer. In conclusion, a study of 101,764 men, reported in the Medical Journal of Australia that men who maintained a physically active lifestyle, drank moderately, had a healthy weight and didn’t smoke were at the least risk for ED, while obese men were 50% more likely and smokers 86% more likely to have ED. And finally in the words of a great quarterback… RELAX!
CERTIFICATION IN UROLOGY NURSING
The Certification Board for Urologic Nurses and Associates (CBUNA) if the only national certification body established to certify urologic nurses and allied health care professionals in urologic nursing practice. To become certified, candidates must pass a 4 hour standardized exam. Individuals successfully completing the certification process may use the following credentials for a period of 3 years:
After the 3 years, certification is renewed for a fee, pending review of mandated continuing education. No further testing is required.
The advantages of certification are numerous.
*Certification improves your skills and knowledge. As you prepare for certification, you will become familiar with topics that you do not routinely encounter in your everyday jog that will add depth to your knowledge base.
*Certification builds self-esteem. Certification is a reflection of your drive to establish your expert knowledge.
*Certification allows peers to recognize you as an expert in your specialty field.
* Certification grants you professional credibility. Certification is an impartial, third-party endorsement of your knowledge and experience. It is the single best way you can testify to your expertise.
I studied for the certification exam every day for 7 months. I was working full time, but I rarely missed a day of studying. My study references included: the SUNA Study Guide for Certification, Smith’s Urology (which I highlighted from beginning to end), the journal articles as well as the study questions in the journal. I made flash cards for the medications. I was very nervous going into the exam. But my preparation served me well, and I obtained a very good score on the exam.
My advice is DO IT! I learned so much. And I have always been proud of the accomplishment.
Nancy M. Mueller, MSN, RN, CURN
Past SUNA President