I. Definition The goal of urodynamic assessment is to characterize the compliance and contractility of the bladder and the function of the outlet (the bladder neck and external sphincter). These tests evaluate bladder pressure, sphincter electromyography, and radiographic imaging of the lower urinary tract. Vesicoureteral reflux may be detected by fluoroscopy during urodynamic assessment and static images can be obtained to grade severity. The urodynamic evaluation includes voiding cystourethrogram (VCUG, performed under supervision by Radiology Department and in compliance with State Fluoroscopic requirements), electromyetrogram (EMG), and cystomyetrogram (CMG). II. Background Information A. Setting: The setting (inpatient vs outpatient) and population (adults vs pediatrics) for the Advanced Health Practitioner (AHP) is determined by the approval of the privileges requested on the AHP Privilege Request Form. If the procedure is being done on a Pediatric patient, make sure Child Life Services is involved and use age appropriate language and age appropriate developmental needs with care of children, as appropriate to the situation. B. Supervision: The necessity of this procedure will be determined by the AHP in collaboration with the supervising physician or his/her designee. Designee is defined as another attending physician who works directly with the supervising physician and is authorized to supervise the AHP. Direct supervision will not be necessary once competency is determined, as provided for in the protocol. The AHP will notify the physician immediately upon being involved in any emergency or resuscitative events or under the following circumstances: 1. Patient decompensation or intolerance to the procedure 2. Bleeding that is not resolved 3. Outcome of the procedure other than expected C. Indications: Patients presenting with history of UTI, incontinence, neurogenic bladder and/or spina bifida. D. Precautions/Contraindications 1. Active UTI 2. Traumatic catheterization 3. Use Latex Precautions 1
III. Materials 1. Feeding tube or CMG catheter 2. Sterile urinary catheterization kit 3. Sterile radio-opaque contrast 4. EMG patches 5. Urodynamics set up by Staff 6. Lead aprons and thyroid shield for staff and family members IV. Urodynamic Assessment A. Pre-treatment evaluation 1. Clinical history provided by the patient, family and/or primary care takers. 2. Patient history provided by hospital and outside charts and radiographs. 3. Assess for pain B. Set up (if applicable) 1. Equipment for CMG, EMG and VCUG will be set up by nursing staff in the appropriate procedure room. 2. All films will be reviewed with the Urologist and family and an appropriate plan initiated. C. Patient Preparation 1. Patient and caregiver(s) will be brought to procedure room and prepared by nursing staff. 2. Patient/caregiver(s) will be asked to empty patient s bladder per baseline. If the patient catheterizes per baseline then he/she will be instructed to leave the catheter in place for the procedure. 3. Protective lead apron and thyroid shield will be worn by all staff and caregiver(s) in procedure room throughout procedure. 4. The patient will be placed on table and a scout film will be obtained by nursing staff and radiology technician. 5. EMG pads will be placed on the patient s perineum by nursing staff and/or AHP. The ground for the EMG will be placed on patient s lower extremity by nursing staff and/or AHP. 2
D. Procedure 1. If a catheter was not used to empty the bladder, a urinary catheter will be placed and secured by nursing staff and/or AHP. 2. The catheter will then be attached to the CMG tubing with radiopaque contrast solution. 3. The CMG tubing will be unclamped and the bladder will be filled slowly with the contrast solution. 4. Fluoroscopy may be ordered to assure placement of catheter and to assess urinary tract during filling as needed according to CMG and EMG readings. 5. Throughout filling and voiding the CMG activity, EMG activity urethral area and urinary ostomy sites will be monitored continuously. 6. Once bladder is full (as determined by patient s sensation of fullness as expressed verbally, by physical observation/exam or patient reaches normal capacity for age), static images may be taken by radiology technician in the supine flat, left oblique and right oblique positions. 7. Patient will be asked to void, or filling will be continued until patient voids spontaneously, and a voiding image will be taken by radiology technician. If patient does not void, then bladder will be emptied via catheter per baseline. 8. Once patient and/or caregiver(s) feel(s) they have voided or catheterized to completion, a post void/catheterization film will be taken by radiology technician. E. Post-procedure 1. If there is no post-void residual, then the patient will be instructed by nursing staff to dress and proceed to waiting room. 2. If there is a post-void residual, the bladder will be emptied to completion via catheter by nursing or repeat voiding. Once the bladder has been emptied to completion, the patient/family will be instructed by nursing staff to dress and proceed to waiting room. 3. A Radiologist reviews all films. All films will be reviewed with the Urologist and family and an appropriate plan initiated. F. Follow-up treatment 1. Follow-up treatment may include but is not limited to prophylactic antibiotics, clean intermittent catheterization (CIC), anticholinergic medication, timed voiding, voiding diary, referral to continence clinic, referral to urology attending. 2. Films are to be reviewed by urology attending within 72 hours. 3. The AHP will consult immediately with the urology attending in situations where the assessment requires prompt diagnostic and/or therapeutic intervention and will initiate appropriate treatment per physician. 3
G. Termination of treatment 1. The bladder may be filled once or twice during the study, after which the study is completed. 2. At any time if the patient is unable to continue with the study, the study will also be terminated. V. Documentation A. Documentation is in the electronic medical record 1. Documentation of the pretreatment evaluation, consent, and any abnormal physical findings. 2. Record the time out, indication for the procedure, procedure, the outcome, how the patient tolerated the procedure, medications (drug, dose, route, & time) given, complications, and the plan in the note, as well as any teaching and discharge instructions. 3. Urodynamic flow sheet will be completed B. All abnormal findings are reviewed with supervising physician. VI. Competency Assessment A. Initial Competence 1. The AHP will be instructed on the efficacy and the indications of this therapy and demonstrate understanding of such. 2. The AHP will demonstrate knowledge of the following: a. Medical indication and contraindications of urodynamic assessment b. Risks and benefits of the procedure c. Related anatomy and physiology d. Consent process e. Steps in performing the procedure f. Documentation of the procedure g. Ability to interpret results and implications in management. 3. AHP will observe the supervising physician perform each procedure three times and perform the procedure three times under direct supervision. 4. Supervising physician will document AHP s competency prior to performing procedure without direct supervision. 5. The AHP will ensure the completion of competency sign-off documents and provide a copy for filing in their personnel file and a copy to the medical staff office for their credentialing file. B. Continued proficiency 1. The AHP will demonstrate competence by successful completion of the initial competency. 4
2. Each candidate will be initially proctored and signed off by an attending physician. AHP must perform this procedure at least three times per year. In cases where this minimum is not met, the attending, must again sign off the procedure for the AHP. The AHP will be signed off after demonstrating 100% accuracy in completing the procedure. 3. Demonstration of continued proficiency shall be monitored through the annual evaluation. 4. A clinical practice outcomes log is to be submitted with each renewal of credentials. It will include the number of procedures performed per year and any adverse outcomes. If an adverse outcome occurred, a copy of the procedure note will be submitted. VII. RESPONSIBILITY Questions about this procedure should be directed to the Chief Nursing and Patient Care Services Officer at 353-4380. VIII. HISTORY OF POLICY Revised Oct 2012 by Subcommittee of the Committee for Interdisciplinary Practice Reviewed Oct 2012 by the Committee on Interdisciplinary Practice Prior revision Nov 2008 Approved Oct 2012 by the Executive Medical Board and the Governance Advisory Council. This procedure is intended for use by UCSF Medical Center staff and personnel and no representations or warranties are made for outside use. Not for outside production or publication without permission. Direct inquiries to the Office of Origin or Medical Center Administration at (415) 353-2733 5