排尿障礙治療中心 版權所有 Lower Urinary Tract Symptoms in Women Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

排尿障礙治療中心 版權所有 Female Lower Urinary Tract Symptoms  Storage symptoms Frequency, Urgency, Nocturia Incontinence Suprapubic fullness and pain  Empty symptoms Hesitancy, Intermittency, Small caliber, Dysuria, Residual urine sensation

排尿障礙治療中心 版權所有 Differential Diagnosis of LUTS in Women  Increased bladder sensation  Detrusor overactivity (idiopathic, neurogenic)  Detrusor underactivity  Bladder outlet obstruction  Interstitial cystitis and painful bladder syndrome  Poor relaxation of pelvic floor muscles  Mixed urinary incontinence  Pelvic floor relaxation and prolapse

排尿障礙治療中心 版權所有 Voiding Diary  3-day voiding diary  Including incontinence episode  Urine amount  Drinking amount  Nocturnal urine amount  Nocturnal frequency

排尿障礙治療中心 版權所有 Voiding Diary

排尿障礙治療中心 版權所有 Initial Assessment  Abdominal physical examination Bladder, Operation scar  Perineal examination Cystocele, Rectocele, Uterine prolapse Urine leakage on cough, fistula Vaginal mucosa, Vaginal tenderness  Neurological examination B-C Reflex, PFM contractility, Anal tone

排尿障礙治療中心 版權所有 Cystoscopy Specific and nonspecific cystitis

排尿障礙治療中心 版權所有 Cystoscopy Irradiation cystitis

排尿障礙治療中心 版權所有 Cystoscopy Bladder cancer

排尿障礙治療中心 版權所有 Sonography of Lower Urinary Tract

排尿障礙治療中心 版權所有 Transrectal LUT Sonography

排尿障礙治療中心 版權所有 TRSB – Urethral anatomy

排尿障礙治療中心 版權所有 TRSB in Continent Woman

排尿障礙治療中心 版權所有 TRSB – Bladder neck incompetence

排尿障礙治療中心 版權所有 Role of External Sphincter in Urgency Frequency Syndrome and Stress Incontinence PatientsN Cross-Sectional Area (mm 2 ) Smooth Muscle Component (mm 2 ) Striated Muscle Component (mm 2 ) A.Control ± ± ± 35.3 B.FUS ± ± ± 23.9 C.Mild SUI ± ± ± 20.9 D.Severe SUI ± ± ± 22.8 Cystocele* (9)75.7 ± ± ± 22.8 Total ± ± ± 25.1 Statistics B vs C: P =0.002 NS B vs C: P =0.002 Others NS B vs D: P =0.005 Others NS

排尿障礙治療中心 版權所有 Cystography and Radiology

排尿障礙治療中心 版權所有 Tentative Diagnosis  Acute cystitis- evidence of pyuria  Hypersensitive bladder – small voided volume & normal flow pattern  Detrusor overactivity – urge incontinence  Bladder outlet obstruction- low flow rate, obstructive flow pattern, residual urine  Pelvic floor hypertonicity – intermittent flow  Interstitial cystitis – lower abdominal pain at a full bladder  Prolapse and pelvic floor relaxation

排尿障礙治療中心 版權所有 Urodynamic Study  Uroflowmetry  Cystometry  Urethral sphincter EMG  Urethral pressure profilometry  Pressure flow multi-channel study  Videourodynamic study  Residual urine volume

排尿障礙治療中心 版權所有 Differential Diagnosis based on Lower urinary tract symptoms  Hypersensitive bladder – normal flow rate  Overactive bladder – presence of DI  Contracted bladder – low bladder compliance  Spastic urethral sphincter – low flow rate, large residual urine, poor relaxed sphincter EMG  Interstitial cystitis – lower abdominal pain at full bladder, small capacity, low compliance, positive KCl test

排尿障礙治療中心 版權所有 Normal Uroflowmetry in Taiwanese Women AgeNumber Voided Volume(ml) Qmax (ml/sec) Cqmax Qmean (ml/sec) Flow Time (sce) ≦ ±84.51 (12) 28.53±6.15 (12) 1.76±0.58 (12) 11.57±5.83 (12) 38.9±35.32 (12) ± (39) 30.22±9.38 (39) 1.73±0.57 (39) 12.17±8.77 (39) 42.46±38.87 (39) ± (60) 28.73±7.63 (60) 1.71±0.51 (60) 12.75±6.31 (60) 28.39±20.48 (60) ± (61) 28.47±11.08 (61) 1.84±1.57 (61) 11.61±6.15 (61) 32.08±22.74 (61) ± (38) 25.68±6.75 (38) 1.46±0.35 (38) 10.86±6.81 (38) 40.25±25.99 (38) ≧ ± (17) 27.78±10.26 (17) 1.71±0.42 (17) 10.80±4.75 (17) 25.67±14.94 (17) Regression analysisP=0.7626P=0.07P=0.5648P=0.2382P= Total (227) ±9.10 (227) 1.71±0.92 (227) 11.83±6.76 (227) 34.22±26.91 (227)

排尿障礙治療中心 版權所有 Differential Diagnosis by Qmax  A normal Qmax excludes most of bladder outlet obstruction  A low flow rate cannot differentiate BOO from low detrusor contractility  Women with hypersensitive bladder and DI often have a low Qmax  Residual urine measurement is important

排尿障礙治療中心 版權所有 Uroflowmetry – Normal flow

排尿障礙治療中心 版權所有 Uroflowmetry – Low contractility

排尿障礙治療中心 版權所有 Uroflowmetry – Obstructive flow

排尿障礙治療中心 版權所有 Uroflowmetry – Straining flow

排尿障礙治療中心 版權所有 Pressure flow study & Videourodynamic study  The most accurate diagnosis for female frequency urgency syndrome  Direct visualization of bladder outlet during filling and voiding phases  Leak-point pressure measurement  Provide fruitful lower urinary tract information

排尿障礙治療中心 版權所有 Multi-channel Pressure Flow Study

排尿障礙治療中心 版權所有 Urodynamic Parameters in Non- obstructive Taiwanese Women NPdet.QmaxQmax Voided volume ResiduumDI SUI ± 7.0 (16.16,17.84) 19.6 ± 8.1 (18.6,20.55) ± (326.6,354.29) 20.2 ± 26.9 (17.01,23.48) 36 (13.4%) LUTS ± 7.1 (19.01,20.83) 17.1 ± 7.7 (16.1,18.11) ± (287.3,318.69) 22.0 ± 32.3 (17.87,26.17) 60 (25.5%)

排尿障礙治療中心 版權所有 Pressure flow study – DHIC

排尿障礙治療中心 版權所有 Pressure flow study– Cystocele and BOO in woman

排尿障礙治療中心 版權所有 Low contractility & low flow

排尿障礙治療中心 版權所有 Detrusor instability in Storage phase

排尿障礙治療中心 版權所有 DI in contracted bladder

排尿障礙治療中心 版權所有 SCI & NVD – Type 1 DESD

排尿障礙治療中心 版權所有 Provoked DI in storage phase

排尿障礙治療中心 版權所有 Urethral Pressure Profilometry

排尿障礙治療中心 版權所有 Urethral Pressure Profile in Normal Taiwanese Women AgeNumber MUCP (cmH 2 O) FPL (cm) ≦ ±39.43 (7)2.86±0.44 (7) ±22.78 (21)2.89±0.47 (21) ±26.95 (29)2.85±0.59 (29) ±32.16 (28)2.98±0.83 (28) ±26.09 (21)2.88±0.66 (21) ≧ ±26.13 (8)2.71±0.59 (8) Regression analysisP=0.0010P= Total ±29.80 (114)2.89±0.65 (114)

排尿障礙治療中心 版權所有 Stress UPP in Incontinent woman

排尿障礙治療中心 版權所有 Nitric oxide UPP in Neuropathic bladder

排尿障礙治療中心 版權所有 Voluntary Pelvic floor contraction

排尿障礙治療中心 版權所有 Differential Diagnosis of Urinary Incontinence  Genuine stress incontinence  Detrusor overactivity incontinence  Mixed stress and urge incontinence  Neurogenic detrusor overactivity incontinence  Intrinsic sphincteric deficiency  Chronic retention & incontinence

排尿障礙治療中心 版權所有 Abdominal Leak point pressure in Type I GSI

排尿障礙治療中心 版權所有 Cough vs Valsalva LPP in Type II/III SUI

排尿障礙治療中心 版權所有 Cough vs Valsalva LPP in Pure Type III SUI

排尿障礙治療中心 版權所有 CVA and Detrusor overactivity incontinence

排尿障礙治療中心 版權所有 Poor compliant bladder and Stress urinary incontinence

排尿障礙治療中心 版權所有 Female Bladder Outlet Obstruction  6-9% in the women with LUTS refractory to medication  Difficult to be diagnosed due to lack of diagnostic criteria  Image study is necessary in addition to pressure flow results  Cystscopy is not always conclusive

排尿障礙治療中心 版權所有 Bladder Neck Dysfunction in Female BOO

排尿障礙治療中心 版權所有 Videourodynamic study in Female urethral stricture

排尿障礙治療中心 版權所有 Videourodynamic study in Female urethral stricture

排尿障礙治療中心 版權所有 Poor relaxation of urethral sphincter

排尿障礙治療中心 版權所有 Low pressure and BOO

排尿障礙治療中心 版權所有 Dysfunctional voiding in woman with urge incontinence

排尿障礙治療中心 版權所有 Comparison of Qmax in BOO and Non-obstructive Women

排尿障礙治療中心 版權所有 Comparison of Voiding Pressure in Women with BOO

排尿障礙治療中心 版權所有 Nomogram of Pressure flow Plot in Women with BOO

排尿障礙治療中心 版權所有 No-pathological Conditions  Habitual frequency and urgency  Hyperosmolar diuresis  Nocturnal polyuria  Polydipsia  Diuretic medication  Conditional reflex ?

排尿障礙治療中心 版權所有 Treatment options- Medical Treatment  Alpha-blocker  Anticholinergic drugs  Skeletal muscle relaxant  Adrenergic agonist  DDAVP  Estrogen replacement  Botulinum toxin

排尿障礙治療中心 版權所有 Efficacy of DDAVP in Nocturnal polyuria BaselinePosttreatment P Value (Paired t Test) Nocturjal frequency (times/night) 5.20 ± ± 1.12< Noctunal urine volume (mL) ± ± < Quality of life 4.47 ± ± 0.91< Urine specific gravity ± ± Serum sodium (mEq/L) ± ± Serum Potassium (mEq/L) 4.46 ± ±

排尿障礙治療中心 版權所有 Intravesical Therapy  Ditropan  Capsaicin- 1mM for DH, 1uM for HSB  Resiniferatoxin- 1uM for DH, 10nM HSB  Heparin- for IC  DMSO- for IC  Xylocaine

排尿障礙治療中心 版權所有 Resiniferatoxin Intravesical Therapy for detrusor overactivity

排尿障礙治療中心 版權所有 Heparin Intravesical Therapy for Urothelial Leak Syndrome Baseline3 mo p value FSF (mL)96.5 ± ± US (mL)225.4 ± ± Cystometric capacity (mL)262.0 ± ± Pdet Qmax (cmH 2 O)25.7 ± ± Qmax (mL/sec)12.9 ± ± Residual urine (mL)29.4 ± ± IPSS (points)19.5 ± ± Nocturia (times/might)5.7 ± ± Pain scale of KCl (points)3.2 ± ± FSF = first sensation of filling; US = urge sensation; Pedt Qmax = detrusor pressure at maximal flow rate; Qmax = maximal flow rate; IPSS = International Prostate Symptom Score.

排尿障礙治療中心 版權所有 Botulinum Toxin injections  Injection to detrusor muscle – for detrusor hyperreflexia & instability  Periurethral injection- DESD, dysfunctional voiding, poor relaxation of urethral sphincter  Subtrigonal injection- for IC(?) or refractory DI (?)

排尿障礙治療中心 版權所有 Urethral Pressure Profile before and after Botulinum toxin injection

排尿障礙治療中心 版權所有 Urethral Dilataion  Effective for urethral stricture  Effective for dysfunctional voiding when combined with estrogen therapy  Ineffective if severe bladder neck scarring  Psychogenic effect ?

排尿障礙治療中心 版權所有 Physical Therapy  Pelvic floor muscle exercise  Biofeedback  Electrical stimulation  Sacral root stimulation  Electromagnetic current

排尿障礙治療中心 版權所有

Surgical Treatment  Sling procedure – urethral incontinence  TUI-Bladder neck – bladder neck dysfunction, Idiopathic BN obstruction  Cystoscopic hydrodilatation  Enterocystoplasty- severe IC