1. 排尿障礙治療中心 版權所有 Stress Urinary Incontinence Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

2. 排尿障礙治療中心 版權所有 Incontinence Definition Failure of voluntary control of urination causing loss of urine per urethra

3. 排尿障礙治療中心 版權所有 Types of Incontinence by symptomatology Continuous or total incontinence Urge incontinence Stress incontinence Overflow incontinence Transient incontinence Giggle incontinence

4. 排尿障礙治療中心 版權所有 Types of Incontinence by Pathophysiology Bladder related incontinence Detrusor overactivity Detrusor underactivity & low compliance Urethral related incontinence Intrinsic sphincteric deficiency Hypermobility of bladder neck & urethra Mixed type of incontinence

5. 排尿障礙治療中心 版權所有 Continence mechanism Stable bladder High position of bladder neck Good urethral coaptation Competent bladder neck Positive pressure transmission ratio Reflex contraction of periurethral muscles

6. 排尿障礙治療中心 版權所有 Extrinsic Continence Mechanism Pubourethral & pubovesical ligaments Pubocervical fascia Attachments to archus tendineus fascia pelvic Vaginal endopelvic fascia Attachments to levator ani Uterosacral ligaments

7. 排尿障礙治療中心 版權所有 Pubovesical pubourethral and pubocervical ligaments

8. 排尿障礙治療中心 版權所有 Extrinsic continence mechanism The Levator ani muscles

9. 排尿障礙治療中心 版權所有 Extrinsic continence mechanism The puborectalis muscles

10. 排尿障礙治療中心 版權所有 Extrinsic continence mechanism The Uterosacral ligaments

11. 排尿障礙治療中心 版權所有 Extrinsic continence mechanism

12. 排尿障礙治療中心 版權所有 Attachments of endopelvic fascia

13. 排尿障礙治療中心 版權所有 Defects in Exterinsic continence mechanism Hypermobility of Bladder neck and urethra Loss of hammock effect during increased abdominal pressure Low pressure transmission ration to urethra Causing cystocele or stress incontinence Coexisting prolapse

14. 排尿障礙治療中心 版權所有 Causes of defects in Extrinsic continence mechanisms Multiple childbirth Hysterectomy Menopause Surgical trauma Peripheral neuropathy (Pudendal nerve) Ageing process Chronic debilitative diseases

15. 排尿障礙治療中心 版權所有 Hypermobility of Bladder neck & urethra

16. 排尿障礙治療中心 版權所有 Low pressure transmission ratio

17. 排尿障礙治療中心 版權所有 Cystocele formation in defects of extrinsic continence mechanism

18. 排尿障礙治療中心 版權所有 Intrinsic Continence Mechanism Urethral mucosa Submucosal vasculature Connective tissue Urethral smooth muscles Urethral striated muscles

19. 排尿障礙治療中心 版權所有 Urethral muscles Urethral smooth muscle Thick inner longitudinal & outer circular m. Pudendal anesthesia cannot block Urethral striated muscle Surround smooth muscle coat about 20-64% of urethral length mainly of slow twitch fibers muscle blocker blocks 40% of muscle tone

20. 排尿障礙治療中心 版權所有 Anatomy of female urethra

21. 排尿障礙治療中心 版權所有 Changes of maximal urethral closure pressure with age AgeNumberMUCP (cmH 2 O) FPL (cm) ≦ 29 1290.28±39.43 (7)2.86±0.44 (7) 30-393981.52±22.78 (21)2.89±0.47 (21) 40-496172.40±26.95 (29)2.85±0.59 (29) 50-596266.74±32.16 (28)2.98±0.83 (28) 60-694063.19±26.09 (21)2.88±0.66 (21) ≧ 70 2353.36±26.13 (8)2.71±0.59 (8) Regression analysisP=0.0010P=0.8279 Total23770.75±29.80 (114)2.89±0.65 (114)

22. 排尿障礙治療中心 版權所有 Anatomical classification of SUI Type I: hypermobility of bladder neck without loss of urethrovesical angle Type II: hypermobility of bladder neck with inferior and external rotation of VUJ Type III: intrinsic sphincteric deficiency with none or minimal hypermobility Mixed type II & III SUI

23. 排尿障礙治療中心 版權所有 Classification of SUI by Leak-point pressures Type 1 SUI : Abdominal leak-point pressure >120cm water with hypermobility Type 2 SUI : ALPP >90 cm water with urethral hypermobility Mixed type 2 & 3 SUI : 60 <ALPP< 90 with hypermobility Type 3 SUI : ALPP < 60 cm water without hypermobility

24. 排尿障礙治療中心 版權所有 Cough vs Valsalva LPP Cough induced reflexic contraction of levator ani and enhance urethral closure by vaginal endopelvic fascia, against urethral resistance and extrinsic continence mechanism Valsalva maneuver causing bearing down of pelvic floor muscles, against intra-urethral resistance CLPP > VLPP in most cases with SUI

25. 排尿障礙治療中心 版權所有 Continence mechanism and LPP

26. 排尿障礙治療中心 版權所有 Grades of Stress incontinence Rare: occur less than 1/month, small amount, no pad protection Minimal: occur only with severe straining, small amount, no pad protection Moderate: occur with mild straining, pad protection is needed Severe: occur with changing position or total incontinence

27. 排尿障礙治療中心 版權所有 Diagnosis of stress incontinence Symptomatology: grades of SUI, types of urinary incontinence Physical signs: demonstration of incontinence or fistula, associated with cystocele or uterine prolapse Endosonography of bladder & urethral Urodynamic study Leak point pressure measurement

28. 排尿障礙治療中心 版權所有 Physical examination of SUI Cystocele Uterine prolapse

29. 排尿障礙治療中心 版權所有 Ectopic ureteral orifice & urinary incontinence

30. 排尿障礙治療中心 版權所有 Urodynamic study for SUI Routine cystometry cannot confirm SUI, but can diagnose detrusor overactivity and low compliant bladder Leak point pressure is a better diagnostic tool to stage stress incontinence Maximal urethral closure pressure has a low but significant correlation with ISD

31. 排尿障礙治療中心 版權所有 Poor compliant bladder and SUI

32. 排尿障礙治療中心 版權所有 Detrusor instability and mild Intrinsic sphincter deficiency

33. 排尿障礙治療中心 版權所有 Videourodynamics in SUI Videourodynamic study can determine leak point pressures and the bladder neck hypermobility during stress Leakage of urine is clearly demonstrated and the accurate leak point pressure can be measured Concomitant pressure flow study to avoid misdiagnosis of bladder outlet obstruction

34. 排尿障礙治療中心 版權所有 Detrusor overactivity without Anatomical stress incontinence

35. 排尿障礙治療中心 版權所有 Uterine prolapse and cystocele causing bladder outlet obstruction

36. 排尿障礙治療中心 版權所有 Reduction of prolapse relieves BOO in patient with SUI

37. 排尿障礙治療中心 版權所有 Measuring LPP and Pressure flow study in SUI

38. 排尿障礙治療中心 版權所有 Leak point pressure in SUI Cough LPP and Valsalva LPP should be measured concomitantly VLPP measures intrinsic urethral resistance CLPP measures resistance from intrinsic and extrinsic continence mechanisms Measure the pressure at exactly the point that urine loss

39. 排尿障礙治療中心 版權所有 Cough v Valsalva Leak-point pressure

40. 排尿障礙治療中心 版權所有 Pelvic Floor Relaxation Low LPP without Hypermobility

41. 排尿障礙治療中心 版權所有 Pelvic Floor Relaxation High LPP with hypermobility

42. 排尿障礙治療中心 版權所有 Pelvic Floor Relaxation CLPP>VLPP, mild hypermobility

43. 排尿障礙治療中心 版權所有 Pelvic Floor Relaxation CLPP=VLPP with hypermobility

44. 排尿障礙治療中心 版權所有 Mechanisms causing leak-point pressures and Hypermobility

45. 排尿障礙治療中心 版權所有 Urethral pressure profilometry in Diagnosis of SUI Perfusion UPP or microtip catheter UPP A lower MUCP was measured by microtip catheter A lower MUCP is associated with a lower Valsalva LPP (p=0.011) and cough LPP (p= 0.005) Dynamic UPP to measure pelvic floor muscle contractility and effect on urethra

46. 排尿障礙治療中心 版權所有 Good PTR and Pelvic floor contraction pressure

47. 排尿障礙治療中心 版權所有 Low PTR and good pelvic floor contraction pressure

48. 排尿障礙治療中心 版權所有 Equal pressure transmission in urethra during stress UPP

49. 排尿障礙治療中心 版權所有 Higher pelvic floor muscle contraction pressure at distal urethra

50. 排尿障礙治療中心 版權所有 Correlation of MUCP with VLPP and CLPP

51. 排尿障礙治療中心 版權所有 Endosonoraphy of Bladder and urethra in SUI

52. 排尿障礙治療中心 版權所有 Measurement of Urethral striated muscle component

53. 排尿障礙治療中心 版權所有 Poor urethral striated muscle component in type III SUI

54. 排尿障礙治療中心 版權所有 Reduced striated muscle component in SUI PatientsN Cross-Sectional Area (mm 2 ) Smooth Muscle Component (mm 2 ) Striated Muscle Component (mm 2 ) A.Non-SUI51104.4 ±35.646.1±22.558.3±27.3 B.SUI6086.7 ±29.943.9±19.042.8±20.7 Cystocele*(9)75.7 ±23.137.9±12.237.8±22.8 Statistics A vs B: P =0.005 NS A vs B: P =0.001

55. 排尿障礙治療中心 版權所有 Measurement of hypermobility of bladder neck

56. 排尿障礙治療中心 版權所有 Measurement of hypermobility and pubourethral ligaments

57. 排尿障礙治療中心 版權所有 Increased rotational angle but not pubourethral length by endosonographic classification of SUI Types of SUI1 (n=25)2 (n=31)3 (n=31)4 (n=12)5 (n=3)Statistics 1 PV angle Resting(degrees) 25±14.233.7±17.139±17.475.8±13.146.7±47.3P<0.01 Straining42.4±18.964.4±2082.6±21.9109±12.450±53P<0.01 Increase17.4±15.330.8±15.643.5±19.533.3±8.93.3±5.8P<0.01 Statistics 2 P<0.005 P>0.1 PV length Resting (mm) 22.6±4.822.6±5.719.2±4.621.5±4.219.7±2.9P>0.05 Straining22.5±4.522.8±5.721.1±5.126.3±6.822±7.2P>0.05 Increase0.1±1.590.2±3.041.9±3.724.8±4.942.3±4.51 Statistics 2 P>0.4P>0.3P>0.005 P>0.2

58. 排尿障礙治療中心 版權所有 Diagnosis of Stress Incontinence Determine the underlying pathophysiology causing incontinence Therapeutic modality depends on grades of SUI Correct the exact defects in continence mechanisms Search for coexisting mixed incontinence and vaginal prolapse