Urodynamics Study Report

Patient Name: [patient name]

DOB: [date of birth] Age/Sex: [age and sex]

MRN: [medical record number]

Study Date: [date] Time: [start and stop time]

Facility/Lab: [facility or urodynamics lab name]

Ordering Clinician: [referring provider]

Performing Staff: [technician or nurse name]

Interpreting Clinician: [clinician name and credentials]

Study Type: [Noninvasive UDS / Multichannel UDS / Video UDS / Ambulatory UDS]

Indication and Clinical Questions

(This section is required. Clearly state the indication and list 2–6 explicit clinical questions the study is intended to answer.)

• [Primary indication/symptom complex and relevant prior interventions]
• [Clinical question 1]
• [Clinical question 2]
• [Additional clinical questions as applicable]

Pre-Test Clinical Context

(Briefly summarize pertinent history. Omit this entire section if no relevant context is available.)

[Key symptoms and duration; bladder diary summary if available (daytime void frequency, nocturia, incontinence episodes, typical voided volumes); prior uroflow/PVR trends; neurologic diagnosis and functional status if applicable; pertinent pelvic exam findings (prolapse stage, stress test result)]

Medication Status: [LUT-affecting medications and whether taken as usual or held; note anticipated impact if deviated from usual regimen]

UTI Screening: [Symptoms present/absent; UA/culture status per local protocol]

Components Performed

(List each component with status. If an expected component was omitted, state the reason.)

• Free uroflowmetry: [Performed / Not performed (reason) / Attempted but incomplete (reason)]
• Post-void residual: [Performed / Not performed (reason)] Method: [ultrasound / catheter]
• Multichannel filling cystometry: [Performed / Not performed (reason) / Attempted but incomplete (reason)]
• Provocative testing: [Performed / Not performed (reason)] Types: [cough / Valsalva / position change / other]
• Pressure-flow study (voiding phase): [Performed / Not performed (reason) / Attempted but incomplete (reason)]
• EMG: [Not performed / Surface / Needle] Placement: [location] (Only include if performed)
• Leak point pressure testing: [Performed / Not performed] Maneuver: [cough / Valsalva] (Only include if performed)
• Video-urodynamics: [Not performed / Fluoroscopy / Ultrasound]
• Urethral pressure profilometry: [Performed / Not performed] (Only include if performed)

Technique

Patient Position: [sitting / standing / supine / position changes during test]

Vesical Catheter: [type, lumen configuration, French size]

Abdominal Pressure: [rectal / vaginal], [catheter type and size]

Fill Medium: [saline / saline with contrast] Fill Rate: [mL/min]

Pressure Reference: [leveling method and confirmation maneuvers performed]

Prolapse Reduction: [method used; results with and without reduction] (Only include if applicable)

EMG: [type and electrode placement] (Only include if used)

(For video studies: [contrast type/concentration, imaging timing, key views obtained])

Results — Uroflowmetry and PVR

(Include this section only if uroflowmetry was performed.)

Voided Volume: [mL] Qmax: [mL/s] Average Flow: [mL/s]

Flow Pattern: [continuous / intermittent / plateau / staccato] Patient Position: [position]

PVR: [mL] Method: [ultrasound / catheter] Timing: [immediately post-void / delayed]

Representativeness: [typical for patient / not typical (state why)]

Artifact: [none / describe artifact and impact on interpretability]

Results — Filling Cystometry (Storage Phase)

(Include this section only if filling cystometry was performed.)

Baseline Pressures: [Baseline vesical, abdominal, and detrusor pressures; adequacy of cough/strain transmission]

Sensation and Capacity:

• First sensation of filling: [mL]
• First desire to void: [mL]
• Strong desire to void: [mL]
• Urgency or pain onset: [mL, specify symptom] (Only include if present)
• Maximum cystometric capacity: [mL]
• Reason for stopping fill: [strong desire / leakage / pain / unsafe pressure / protocol volume reached / other]

(If sensation absent or atypical, state explicitly.)

Compliance: [value with calculation interval (start volume/pressure to end volume/pressure)] (If not reliably calculated, state reason.)

Detrusor Overactivity: [For each significant episode: volume at onset (mL), peak detrusor pressure (cmH2O), spontaneous vs provoked (provocation type), associated leakage (yes/no)] (If none observed, state "No detrusor overactivity observed.")

Incontinence During Filling: [Leakage mechanism: with stress maneuvers without detrusor contraction / with detrusor contractions / mixed / unclear mechanism / no leakage observed]

Leak Point Pressure Testing: [Bladder volume (mL); maneuver type; position; leakage pressure with definition used; detrusor stability during maneuver] (Only include if performed)

Results — Pressure-Flow Study (Voiding Phase)

(Include this section only if voiding phase was attempted.)

Permission to void given: [yes / no] Voiding occurred: [yes / no]

Voided Volume: [mL] Qmax during PFS: [mL/s] Pdet at Qmax: [cmH2O]

Opening Pressure: [cmH2O] (Only include if assessed)

PVR after PFS: [mL] Method: [ultrasound / catheter]

Voiding Efficiency: [percentage] (Only include if calculated)

Abdominal Straining: [absent / present (describe)]

EMG During Void: [relaxation / paradoxical activity / not recorded] (If dyssynergia suspected, document basis.)

(If unable to void, specify: "Unable to void with catheters in place" vs "Acontractile tracing" vs reason for termination. Do not infer obstruction when voiding did not occur; state "voiding phase not assessable.")

Obstruction/Contractility Indices: [value(s), inputs used, population context] (Only include if calculated)

Imaging Findings (Video-Urodynamics Only)

(Include this section only if video-urodynamics was performed.)

• Filling phase: [Bladder contour, trabeculation, diverticula, bladder neck behavior, vesicoureteral reflux (presence, laterality)]
• Voiding phase: [Bladder neck opening, urethral opening pattern, reflux if observed, anatomic explanation for obstruction if visualized]

[Radiation/contrast documentation per local standards] (Include if required)

Quality, Reliability, and Limitations

(This section is required.)

Technical Quality: [Cough pressure transmission: adequate/limited; signal issues: drift, dead signal, poor transmission, catheter displacement, or none; artifacts: pump vibration, tube knock, rectal contractions, or none; trace display: adequate scaling or issues noted]

Clinical Representativeness: [Symptoms reproduced: yes/no/partially; deviations from usual state: medications not taken as usual, atypical fluid intake, suspected UTI, pain/anxiety, position limitations, or none]

Reliability Statement: (Required) "Study adequate for interpretation of: [storage phase / voiding phase / both / neither]." [If limited, specify which conclusions cannot be made.]

Interpretation

(Provide phase-based answers to the stated clinical questions. Avoid conclusions not supported by recorded data.)

Storage Phase:

• Sensation pattern: [normal / abnormal (specify) / not assessable]
• Capacity: [low / normal / high] (correlate with bladder diary if available)
• Compliance: [normal / reduced / not measurable]
• Detrusor overactivity: [present (explain symptom correlation) / absent]
• Incontinence mechanism: [stress supported / urge supported / mixed / uncertain / none observed]

Voiding Phase:

• Coordination: [normal detrusor contraction with outlet relaxation / not assessable]
• Pattern consistent with: [normal voiding / bladder outlet obstruction / detrusor underactivity or acontractility / dysfunctional voiding or dyssynergia / not assessable]
• Incomplete emptying: [degree and likely mechanism] (Only include if voiding data exist)

Urodynamic Diagnosis(es): (Use standardized terminology; list safety-threatening findings first)

• [Diagnosis 1]
• [Diagnosis 2] (Only include if applicable)
• [Diagnosis 3] (Only include if applicable)

Correlation Statement: [Whether findings are consistent with reported symptoms and whether symptoms were reproduced during testing]

Management Implications

(Limit to implications directly supported by urodynamic findings.)

• [Impact on proposed interventions: supports/argues against planned procedure; suggests addressing specific dysfunction first]
• [Safety implications requiring timely action: high storage pressures, poor compliance, severe retention] (Only include if applicable)
• [Next diagnostic step if needed to resolve uncertainty: repeat study, video UDS for obstruction site] (Only include if applicable)

Attachments

• [Key urodynamic tracings/printouts]
• [Pressure-flow plots and calculated indices] (Only include if applicable)
• [Key fluoroscopy images] (Only include for video UDS)

Interpreting Clinician Signature: [electronic signature with date and time]