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

2. 排尿障礙治療中心 版權所有 Definition of Overactive Bladder  A medical condition referring to the  Symptoms of frequency and urgency,  With or without urge incontinence  In the absence of local pathology or metabolic factors that would account for these symptoms  A profound impairment of quality of life due to urge and frequency

3. 排尿障礙治療中心 版權所有 Overactive bladder  Sensory urgency (hypersensitivity)  Motor urgency (detrusor overactivity) Detrusor instability (non-neurogenic) Detrusor hyperreflexia (neurogenic)

4. 排尿障礙治療中心 版權所有 Symptomatology of Overactive bladder  Those with frequency and urgency  Those with frequency urgency and urge incontinence  Those with mixed stress and urge incontinence

5. 排尿障礙治療中心 版權所有 Sensory urgency  Might be a micro-motor urgency due to micro-motion of detrusor during bladder filling  Rapid bladder filling  Diuresis  Detrusor instability can be elicited by 0.4M KCl or resiniferatoxin instillation

6. 排尿障礙治療中心 版權所有 Detrusor overactivity  Neurogenic detrusor hyperreflexia  Detrusor instability related to bladder outlet obstruction  Idiopathic detrusor instability  ICS recommended Detrusor overactivity May be neurogenic, myogenic or idiopathic

7. 排尿障礙治療中心 版權所有 Micturition Control

8. 排尿障礙治療中心 版權所有 Incontinence  In women 49% stress incontinence 22% urge incontinence 29% mixed stress & urge  In men 73% urge incontinence  In elderly >65 years, prevalence rate is 33-61%,accompany with incomplete empty

9. 排尿障礙治療中心 版權所有 Non-urological incontinence (Diappers)  Delirium  Infection  Atrophic vaginitis  Psychological disorders  Pharmacological effects  Excessive urine output  Restricted motility  Stool impaction

10. 排尿障礙治療中心 版權所有 Urodynamic finding in Detrusor overactivity  An involuntary rise in detrusor pressure during the filling phase of a urodynamic study  Associated with an urge sensation or urine leakage  May associate with a low bladder compliance, but phasic detrusor contractions should exist

11. 排尿障礙治療中心 版權所有 Neurogenic Detrusor overactivity  Cerebral vascular accidents  Dementia  Intra-cranial lesions  Parkinson ’ s disease  Supra-sacral cord injuries  Multiple sclerosis

12. 排尿障礙治療中心 版權所有 Detrusor overactivity related to Bladder Outlet Obstruction  Benign prostatic obstruction  Bladder neck dysfunction  Bladder neck stricture  Urethral stricture  Spastic urethral sphincter  Iatrogenic obstruction (after anti- incontinence surgery)

13. 排尿障礙治療中心 版權所有 Idiopathic Detrusor Overactivity  Children & young adult – diurnal enuresis or nocturnal enuresis  Adults women – after delivery, associated with stress incontinence or urgency frequency  Elderly patients of either sex – occult neuropathic or poor cortical perfusion

14. 排尿障礙治療中心 版權所有 Diagnosis of idiopathic detrusor overactivity  Exclude bladder outlet obstruction  Exclude neurogenic lesion  Cystometry with sphincter EMG  Pressure flow study for associated voiding dysfunction  Videourodynamic study to investigate upper tract and urethral conditions concomitantly

15. 排尿障礙治療中心 版權所有 Detrusor overactivity in a child idiopathic detrusor instability

16. 排尿障礙治療中心 版權所有 Detrusor overactivity in a child Pseudodyssynergia & VUR

17. 排尿障礙治療中心 版權所有 Detrusor overactivity in a girl with Pseudodyssynergia

18. 排尿障礙治療中心 版權所有 Detrusor overactivity in a woman with Stress incontinence

19. 排尿障礙治療中心 版權所有 Detrusor overactivity in a woman with BN dysfunction

20. 排尿障礙治療中心 版權所有 Detrusor overactivity in a woman after anti-incontinece surgery

21. 排尿障礙治療中心 版權所有 Detrusor overactivity in a man with BPH obstruction

22. 排尿障礙治療中心 版權所有 Detrusor overactivity in a man after CVA

23. 排尿障礙治療中心 版權所有 Detrusor overactivity in a man with anterior urethral valve

24. 排尿障礙治療中心 版權所有 Detrusor overactivity in a man with Parkinson ’ s disease

25. 排尿障礙治療中心 版權所有 Clinical Presentation of OAB  Frequency & nocturia  Urgency – sudden sensation of strong desire to void, during increasing fullness sensation or in isolation especially during coughing or jumping, changing posture or activities  Urge incontinence – with or without urge sensation, may confused with SUI

26. 排尿障礙治療中心 版權所有 Clinical Presentation of OAB  Bedwetting – not nocturnal enuresis, patient is awaked and has urge sensation  Pain – suprapubic or perineal pain associated with an urge sensation  Psychological symptoms – a high incidence of affective disorders, neuroticism, emotional disturbance, difficulty in interpersonal relationships

27. 排尿障礙治療中心 版權所有 Detrusor overactivity -- Urethra as an etiology ?  Bladder neck incompetence is highly prevalent in women with urgency & urge incontinence  Suspension of the bladder neck cure part of the women with sensory urgency and urge incontinence  Pelvic floor exercises improved urgency frequency, increased capacity, and urge incontinence as well as stress incontinence

28. 排尿障礙治療中心 版權所有 Physical examination for Overactive Bladder  Suprapubic palpation for a chronically distended bladder  Perineal sensation, anal tone, voluntary contraction, bulbocavernous reflex  DRE & vaginal examination for BPH, prolapse, SUI, meatal stricture  Uroflowmetry & cystoscopy  Ultrasound of lower urinary tract

29. 排尿障礙治療中心 版權所有 Voiding Diary for Overactive Bladder

30. 排尿障礙治療中心 版權所有 Detrusor overactivity during urodynamic study  Spontaneous detrusor contractions  Provoked detrusor contractions – coughing, laughing, running water  Low compliance and spontaneous detrusor contractions  Pre-micturition detrusor contraction  Post-micturition after contraction

31. 排尿障礙治療中心 版權所有 Spontaneous detrusor contractions

32. 排尿障礙治療中心 版權所有 Provoked detrusor contractions

33. 排尿障礙治療中心 版權所有 Low compliance and spontaneous detrusor contractions

34. 排尿障礙治療中心 版權所有 Detrusor instability during changing position in CMG

35. 排尿障礙治療中心 版權所有 Pre-micturition detrusor contraction

36. 排尿障礙治療中心 版權所有 Post-micturition after contraction

37. 排尿障礙治療中心 版權所有 Urodynamic diagnosis of Detrusor overactivity  Urgency or urge incontinence: sensitivity 78%, specificity 39%  Cystometry: sensitivity 88%, specificity 75%  Provocative test: increased sensitivity compared with a 30-40% false negative rate in those without provocation  Rapid filling CMG is more provocative  Diuresis CMG is also more provocative

38. 排尿障礙治療中心 版權所有 Detrusor overactivity  Demonstration of involuntary detrusor contraction (>15cm water or phasic contraction with urge sensation) during filling cystometry  Catheter effect should be eliminated  Repeat cystometry with lower filling rate  Ask patients if they are voluntarily to void immediately at urge sensation

39. 排尿障礙治療中心 版權所有 Treatment modalities of Idiopathic Detrusor Overactivity Behavioral therapyBladder drill Timed/prompted toileting Medical therapyAnticholinergic/antimuscarinics Tricyclic antidepressants Neurotoxins Estrogens Electrical therapyVaginal or anal electrical stimulation Trancutaneous electrical simulation Sacral nerve neuromodulation Surgical therapyPartial detrusor myomectomy Augmentation cystoplasty Urinary diversion

40. 排尿障礙治療中心 版權所有 Behavioral Therapy  Incorrect cognition of frequent urination  Education of normal voiding physiology  Avoid irritants or diuretics  Normal fluid intake 1.5 to 2 L daily  Establish cortical control of urgency  Bladder training and pelvic muscle exercises

41. 排尿障礙治療中心 版權所有 Bladder re-education  Gradual increase in voiding intervals  Voiding by the clock rather than by urge  Hold micturition before the voiding time  Suppress detrusor contraction by stopping activity, concentration, crossing leg, pelvic floor contractions  Repeat protocol until voiding interval of 3 hours in the daytime

42. 排尿障礙治療中心 版權所有 Behavioral Therapy with CMG  Attempts to hold urine for increasing length of time during urge to void  May be initiated in bathroom or toilet  Cystometry with EMG can be used if feasible to treat detrusor instability  A 6-week course or longer may be necessary

43. 排尿障礙治療中心 版權所有 Medical Therapy  Modulation of CNS control mechanism  Blockage of peripheral nervous system receptors  Direct relaxation of smooth muscle  Regulation of contractile function  A combination of behavioral therapy with medical therapy is often helpful

44. 排尿障礙治療中心 版權所有 Common medical therapies DrugDoseFrequency Oxybutynin2.5-10 mg2-3 time per day Tolterodine1-4 mgTwice daily Propiverine15 mg2-4 time per day Imipramine10-25 mg1-3 times per day Propantheline7.5-60 mg3-5 times per day Dicyclomine10-20 mg3 times per day Flavoxate200-400 mg3-4 times per day

45. 排尿障礙治療中心 版權所有 Anticholinergics  5 types of muscarinic postganglionic parasympathetic receptors inbody  M2 & M3 subtype in bladder contraction as well as salivary gland and intestine  Side effects include dry mouth, drowsiness, constipation, tachycardia, blurred vision; is contraindicated in glaucoma  Patient may increase fluid intake due to dry mouth and influence the effect on frequency

46. 排尿障礙治療中心 版權所有 Oxybutynin Tolterodine Imipramine  Oxybutynin reduce incontinence by 19 – 58% over placebo  Tolterodine is 8x less affinity for parotid gland M-receptor(40% v 78%), but is equivalent potent than oxybutynin  Imipramine is tricyclic antidepressan with anticholinergic and alpha-adrenergic effects that produce detrusor relaxation and urethral sphincter contraction

47. 排尿障礙治療中心 版權所有 Capsaicin & Resiniferatoxin  Cause excitation and desensitization of C- afferent fibers  Capsaicin in 1-2mM and RTX in 10 -6 M for detrusor hyperreflexia  Increased capacity and reduced detrusor contractility  Hematuria and initial inflammation

48. 排尿障礙治療中心 版權所有 Initial responses of RTX

49. 排尿障礙治療中心 版權所有 Results of RTX in Treatment of Detrusor hyperreflexia BaselinePost-RTXStastistics Cystometric capacity (ml) 102.1±31.5236.6±88.6P<0.001 Bladder compliance (ml/cmH2O) 23.7±12.125.9±15.3P>0.05 Voiding pressure (Pdet, cmH2O) 55.9±23.247.5±28.1P>0.05 Presence of DESD100%

50. 排尿障礙治療中心 版權所有 Change in Bladder capacity after RTX instillation

51. 排尿障礙治療中心 版權所有 Botulinum toxin A injection  Injection of botulinum toxin A directly to detrusor muscle can effectively reduce detrusor overactivity  Detrusor underactivity will develop  Patients may need clean intermittent catheterization  Clinical trial in SCI and severe DH child

52. 排尿障礙治療中心 版權所有 Surgical Therapy  Cystoscopic hydrodilatation  Subtriginal phenol injection  Sacral nerve rhizotomy  Bladder denervation  Partial detrusor myomectomy  Augmentation cystoplasty  Urinary diversion (ileal conduit or Kock pouch formation)

53. 排尿障礙治療中心 版權所有 Complication of surgical therapy  Bladder hyposensitivity  Residual detrusor instability  Incomplete bladder empty  Urinary tract infection  Chronic urinary retention and CISC  Stone or malignancy formation  Metabolic problem (acidosis)

54. 排尿障礙治療中心 版權所有 Detrusor myomectomy

55. 排尿障礙治療中心 版權所有 Detrusor myomectomy ( Autoaugmentation )

56. 排尿障礙治療中心 版權所有 Improved in bladder capacity after autoaugmentation

57. 排尿障礙治療中心 版權所有 Enterocystoplasty- technique

58. 排尿障礙治療中心 版權所有 Augmentation cystoplasty

59. 排尿障礙治療中心 版權所有 Results of Enterocystoplasty Cystometric capacity cmH 2 O End filling pressure cmH 2 O Bladder compliance Ml/cmH 2 O MUCP cmH 2 O Preoperative 165±9750±2310.8±2.762±28 Postoperative 760±28913±4.775±43 － Statistics P<0.005 MUCP=Maximal urethral closure pressure.

60. 排尿障礙治療中心 版權所有 Changes in capacity and bladder pressure after augmentation cystoplasty