Diagnostic Testing
Prior to advise on any treatment correct diagnosis has to be established. Frequently it will
require an additional testing. For patients with urinary incontinence it includes
Urodynamic Testing and/or Cystoscopy if needed. For
patients with fecal incontinence Ano-Rectal manometry and
Pudendal nerves motor latency study.
Only if needed patients with bowel evacuatory difficulties
and/or rectal prolapse might be referred for imaging studies such as
Ano-Rectal Ultrasound, Barium
Enema and/or Defecography as well as
Colon Transit Time.
Diagnostic testing for Patients with Urinary Symptoms
Multichanal Urodynamics:
Urodynamics are simple combination of several useful tests, which provide information about
your lower urinary tract. This information is obtained much in the same way that an
electrocardiogram (EKG) provides information about your heart. Urodynamics "draws a picture"
for your doctor of what happens when your bladder fills up and when it empties. During the test
you will be catheterized at least once. Your bladder will be filled one or more times with water.
Muscle activity in your pelvis will be recorded during the tests by small electrodes similar to
those used in an EKG.
Preparation For Urodynamics:
You have to arrive 30-60 min prior to urodynamic testing to register. It is important to have
a moderately full bladder when you come for the studies; please, be ready to urinate! There are
no other special preparations or food restrictions for this test. If you wear padding, external
catheters, etc., you should bring extra supplies for replacement after the test. You can help
to make the test easier by remaining relaxed. Each step of the evaluation will be explained to
you throughout the test. Every effort will be made to make you as comfortable as possible during
the procedure. An urodynamic evaluation usually includes the following tests.
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Uroflowmetry: A flow rate is done by asking you to void into a special toilet, which records
the pattern of your urine stream on a graph and the amount of urine you void via the electrodes
already described. The amount of urine left in your bladder after you void (residual urine) may
also be measured at this time. It is important that you do not have a bowel movement into the
special toilet during the flow rate test.
Cystometry and Electromyography (CMG/EMG): This test involves filling your bladder through a
catheter with sterile water. We will ask you when you feel the urge to urinate, and when your
bladder feels completely full. Pelvic muscle activity will be recorded as already described.
You may be asked to urinate through the catheter.
Urethral Pressure Profile: Also called UPP - this test provides the doctor with information
about your urethra. A small catheter (usually the same one used for the CMG/EMG) will be slowly
pulled out of your bladder. A small amount of water will be infusing through the tip of the
catheter, making you feel as if you are voiding. Pressures inside your urethra will be recorded
as the catheter is pulled out. Remember to relax as completely as you can. Otherwise, falsely
elevated pressures may result.
After Urodynamics: After urodynamic testing you may experience some burning on urination or some increased frequency
of urination for a short time. Drinking plenty of fluids afterwards will help alleviate this.
You may also have some blood in your urine for a short while, which should be minimal. According
to the latest recommendations by American College of Obstetricians and Gynecologists no antibiotic
prophylaxis required before or after this testing to prevent urinary tract infections. Regardless,
you should notify your doctor if you experience fever, chills, and significant bleeding or severe
discomfort after the urodynamics. These symptoms rarely occur.
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Outpatient Cystoscopy:
This test involves the visualization of the inside of your bladder and urethra. The doctor
will actually see the inside of these structures through a very small instrument, which works
much like a telescope. Your bladder will be filled with a fluid while your doctor examines the
inside of your bladder. A local anesthetic will be applied to the inside of your urethra to make
the introduction of the instrument as comfortable as possible. During the cystoscopy you will be
placed in a position similar to that used for women when giving birth. Your genitalia will be
cleansed with an antiseptic solution prior to the cystoscopy.
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Where The Cystoscopy Will Be Done? Cystoscopy will be performed in the Urodynamics
Laboratory. Simply report to registration desk 30-60 min before your appointment. Cystoscopy
usually takes only 5 minutes to complete. Your doctor will give you the results immediately.
How Do I Prepare for the Examination? No special preparation is necessary for outpatient
cystoscopy. You may eat and drink fluids as you usually do. Please let us know if you are
allergic to iodine as, otherwise, this will be the cleansing solution used.
After Cystoscopy: After the cystoscopy you may experience some burning on urination or some
increased frequency of urination for a short time. Drinking plenty of fluids afterwards will
help alleviate this. You may also have some blood in your urine for a short while, which should
be minimal. To decrease the risk of urinary tract infection, you will be given a few days of
antibiotics to take. You should notify your doctor if you experience fever, chills, severe
bleeding, or severe discomfort after the cystoscopy. These symptoms rarely occur.
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Ano-Rectal Manometry:
Anorectal Manometry is the study of the function of the anus and rectum. Anal manometry is an
evaluation of the strength of the muscles that control your bowel movements. The test is performed
by placing a small tube (the size of a drinking straw) into the rectum. Pressure monitors inside
the tube transmit the muscle impulses to a graph similar to that of an electrocardiogram. It is
a painless procedure that takes about 30 min to perform. Results of the study will help your
physician recommend appropriate medical or surgical treatment for you.
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What Can I Expect? - You will have a brief interview by a physician prior to any testing.
The physician will explain the purpose of the tests performed at the laboratory, and you will
have an opportunity to ask questions.
What Tests are Performed? - Many investigations can be performed. You may be scheduled for
only one or several. The physician will explain the investigations you are scheduled for during
the interview. Some are explained below.
How Long Does It Take? - To conduct the interview and perform all tests takes about 60 min.
If you are not scheduled for all tests, it will take less time. No medications are given. You
can leave immediately after the tests have been performed.
When Will I Know The Test Results? It takes about a few days for your physician to get the
results. He will discuss the results on a later date after he has had a chance to review them.
What Is Electromyography? - If your doctor wishes, we will also perform EMG or
electromyographic testing of the muscles around the anus. These tests allow us to determine
if the nerves that supply your sphincter muscles are intact and that your muscles relax and
contract as they should. These test are performed by placing a small electrode on the nerve
or muscle, and measuring the electrical activity. This is not painful.
How Do I Prepare for the Examination? - You will need to take two Fleet enemas. Take the
first enema 2 hr prior to the test and the second 30 min later. These enemas are available at
any pharmacy. There are no dietary restrictions.
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Pudendal nerves motor latency study:
The external anal sphincter muscle is innervated by the pudendal nerve. The majority of
patients with idiopathic anal incontinence (not related to disruption of the sphincter) have
prolonged pudendal nerve latencies. This technique allows objective quantitation of the
neuromuscular function of the anal sphincter in the setting of incontinence. Pudendal nerve
stimulation was first described for measuring distal pudendal nerve terminal motor latencies by
Kiff and Swash in 1984. Determination of the pudendal nerve terminal motor latency should be used
in conjunction with Ano-Rectal Manometry.
Indications for study as follow:
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- To define the neuromuscular component of sphincter dysfunction in patients with anal
incontinence, thereby aiding in therapeutic decision-making.
- To evaluate the neurological damage done to the pudendal nerve and anal sphincter during
childbirth in attempting to predict sphincter function after future vaginal deliveries or
after sphincter reconstruction. (see picture).
- To assess the neuromuscular function of the anal sphincter before repair of rectal prolapse.
- To assess the neuro-muscular function of the anal sphincter in patients with a long history of
constipation and straining due recto-sigmoid redundancy prior to bowel resection in attempt to
predict the possibility of fecal incontinence.
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Technique: Pudendal nerves terminal motor latency studies can be performed by intrarectal
stimulation of the right and left pudendal nerves at the level of the ischial spines and evoked
response recorded from the external anal sphincter muscle. St. Marks electrode is used to perform
the test.
Interpretation of results: The normal pudendal nerve terminal motor latency has been shown to
be 2.0 ± 0.2 msec (SD). The latency of response is measured from the onset of the stimulus to
the onset of the response in the external anal sphincter (See example). The right and left nerve
latencies may be different but tend to vary only slightly from the mean. In patients with
idiopathic fecal incontinence pudendal nerve terminal motor latencies have been shown to be
prolonged to a mean of 3.0 + 0.9 msec. There is also a correlation between the degree of perineal
descent and the pudendal nerve terminal motor latency.
Patients with a single normal pudendal nerve should notice improvement after anal sphincter
reconstruction. However, bilateral nerve injury as indicated by abnormal pudendal nerve latencies
will prevent recovery of anal sphincter function after repair. The terminal motor latency is the
measurement of the fastest response in the pudendal nerve-external sphincter mechanism. A normal
latency does not indicate absence of nerve damage. Neither does an abnormal latency indicate
abnormal muscle function. Muscle reinnervation as documented by single-fiber densities on
single-fiber EMG is necessary to quantitate damage.
Ano-Rectal Ultrasound:
Ano-Rectal Ultrasound has rapidly become a popular technique for imaging the low rectum,
anal sphincters, and pelvic floor in patients with a variety of anorectal diseases. In contrast
to conventional transcutaneous ultrasonography, which uses externally placed transducers to image
structures within the body cavities, Ano-Rectal Ultrasound places the transducer directly into a
body cavity, within millimeters of the region of interest, thus allowing high levels of
resolution and imaging quality with minimal patient discomfort. Although first utilized in the
1950s by Reid and Wild, this technique was not described again for anorectal imaging until the
early 1980s, when it was primarily used for the staging of rectal cancers. Since then, it has
emerged as a valuable test for evaluating the anatomical condition of the anal sphincters and
pelvic floor. Current indications for anorectal ultra-sonography include the following:
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Fecal incontinence, both traumatic (see pictures) and idiopathic.
Evaluation of complex perianal fistulae/abscesses.
Staging of anal malignancies.
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Preparation involves only a cleansing enema (phosphosoda, 45 ml immediately prior to the exam)
if the patient does not have a tender anal canal. The examination takes only about 10 to 15 min,
and if a comfortable digital anal examination.
Defecography:
A Defecography is a test of the motion of the pelvic floor, the muscles that control a
bowel movement, and the motion of the anus and rectum during evacuation. A small amount of
barium is placed in the rectum, and a recording is made during evacuation of the barium
(see pictures). It takes about 20 min to perform this painless test. This test is not performed
in our lab but you may be referred for this testing to outside institution if needed.
Barium Enema:
A Barium Enema (BE) is an x-ray examination of your colon. Time required is about 30 minutes
to one hour.
Why do I need a Barium Enema? You may need a Barium Enema if you are
having abdominal pain, constipation, diarrhea, or blood in your stool.
How do I prepare for my Barium Enema? You will need to take a bowel
prep the day before your test is scheduled. Carefully follow the instructions on the package.
Drink as many clear liquids, as you want. Do not drink milk or milk products. Examples of clear
liquids are clear Jell-O, tea, black coffee, bouillon, apple juice, Popsicles, ice, water, and
cola. Once the bowel prep is taken, you should not eat or drink anything after midnight the
night before your test.
What can I expect during the test? You will be given an enema by the
radiologist (a physician specializing in x-ray diagnosis). The barium solution will outline your
colon and show up on x-ray film. You may experience some mild cramping for a short period of
time while the films are being made.
What do I do after my Barium Enema? After the Barium Enema, you should
resume your routine diet and medications. You should also drink plenty of liquids. Your stool
will continue to have a whitish color to it until you have expelled all of the barium. If you
experience constipation, you may need to take a mild laxative. Your doctor will discuss the
test results with you. This test is not performed in our lab but you may be referred for this
testing to outside institution if needed.
Colon Transit Time:
A technique for measuring total and segmental colonic transit time is a useful tool in the
evaluation of patients with complaints of severe constipation. Patient reports of stool frequency
are usually inaccurate, and even when accurate, do not correlate well with either total or
segmental colonic transit time. Furthermore, it has become apparent that patients with similar
complaints may have abnormalities of transit that are localized to different segments of the
colon. While the efficacy of various treatments of colonic motility disorders remains relatively
unproven, objective measurements of total and segmental colonic transit provide a portion of the
information necessary to pursue a logical form of treatment and monitor outcome.
