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

2. 排尿障礙治療中心 版權所有 Urinary Tract Infection Acute infection Chronic infection Non-specific UTI Granulomatous UTI- Tuberculosis Genital tract infection Complicated UTI- Surgery, Calculi

3. 排尿障礙治療中心 版權所有 Acute Cystitis The most common form of Female UTI Annual incidence 0.5-0.7/person-year 25% of women have recurrent UTI 1/3 of women have recurrent cystitis within 3 months, 75-80% recur within 2 years Sporadic or recurrent cystitis

4. 排尿障礙治療中心 版權所有 Pathogenesis of recurrent UTI Bacterial factors – Longer duration of colonization of vaginal introitus with pathogenic E. coli Host factors – Women with recurrent UTI are 3-4 times more likely to be nonsecretors of ABH blood-group antigen

5. 排尿障礙治療中心 版權所有 Pathogenesis of recurrent UTI Immune status – local and systemic immune response are weak in women with recurrent UTI Estrogen depletion – Increased susceptibility of UTI in post-menopause women, a lower glycogen content in vaginal epithelium, vaginal bacterial flora shift toward E. coli & G(-) bacilli

6. 排尿障礙治療中心 版權所有 Pathogenesis of recurrent UTI Anatomical factors – Distal urethral meatal stenosis, uterine prolapse, cystocele, increased postvoid residual urine Microbial ecology – Lack of inhibitory effects of hydrogen peroxide producing lactobacilli against pathogenic micro- organisms including E. coli

7. 排尿障礙治療中心 版權所有 Treatment of Acute cystitis First line antibiotics for 7 days 90% self-treatment cure rate Routine culture before therapy is not necessary Prophylactic therapy (>2 UTI / 6Mo) decreases recurrence rate by 95% Nitrofurantoin or sulfamethoxazole once daily for 6 to 12 months

8. 排尿障礙治療中心 版權所有 Acute pyelonephritis (APN) Uncomplicated or complicated APN Ampicillin or broad-spectrum cephalosporin combined with aminoglycoside for 2 weeks For relapsed APN a 6 weeks therapy according to culture is necessary

9. 排尿障礙治療中心 版權所有 Asymptomatic bacteriuria Treatment for asymptomatic pyuria with positive culture is not mandatory Should be treated in diabetic, preganant women as well as women undergoing invasive GU procedures 70-80% pregnant women cured after therapy for 7-10 days

10. 排尿障礙治療中心 版權所有 Management of recurrent UTI Intermittent self-start therapy 92% responded clinically Estrogen therapy – oral or topical estriol Behavioral therapy – increased E coli bacteriuria after sexual intercourse; certain contraceptives alter vaginal flora Anal sex, masturbation, sex during menstruation increase risk for UTI

11. 排尿障礙治療中心 版權所有 Prophylaxis of recurrent UTI Cranberry – contains fructose which interferes adhesion of type I fimbriated E. coli to uroepithelium Acupuncture – 85% vs 58% sham & 36% control group during 6 months Intravesical heparin therapy – prevent bacterial adhesion to urothelium

12. 排尿障礙治療中心 版權所有 Urodynamics and Recurrent UTI in Women Detrusor instability & pseudo- dyssynergia (Dysfunctional voiding) Pelvic floor hypertonicity Detrusor external sphincter dyssynergia Poor compliant bladder Detrusor underactivity & residual urine Bladder outlet obstruction

13. 排尿障礙治療中心 版權所有 Detrusor Overactivity Idiopathic or neuropathic Involuntary contraction of external sphincter at initiation of voiding Increased intravesical pressure at bladder capacity Combined with inadequate contractility in elderly and CVA patients

14. 排尿障礙治療中心 版權所有 Idiopathic Detrusor Overactivity

15. 排尿障礙治療中心 版權所有 Increased Sphincter activity during Detrusor overactivity

16. 排尿障礙治療中心 版權所有 Detrusor instability & Inadequate contractility

17. 排尿障礙治療中心 版權所有 Low bladder compliance and low contractility after surgery

18. 排尿障礙治療中心 版權所有 Pelvic floor hypertonicity Poor relaxation of pelvic floor Low detrusor contractility and low efficient voiding Moderate to large residual urine developed Associated with constipation and increased vaginal colonization of E.coli

19. 排尿障礙治療中心 版權所有 Spastic urethral sphincter & High voiding pressure

20. 排尿障礙治療中心 版權所有 Detrusor underactivity and Low efficient voiding

21. 排尿障礙治療中心 版權所有 Detrusor external sphincter dyssynergia (DESD) Neuropathy in origin High voiding pressure and low bladder compliance Large residual urine Upper tract deterioration

22. 排尿障礙治療中心 版權所有 Detrusor external sphincter dyssynergia in an SCI woman

23. 排尿障礙治療中心 版權所有 Poor Bladder Compliance Increased intravesical pressure at bladder capacity Urothelium damage Increased bacterial adherance to urothelium Diminished detrusor contractility Large residual urine

24. 排尿障礙治療中心 版權所有 Bladder Outlet Obstruction Bladder neck dysfunction Urethral stricture Spastic urethral sphincter Cystocele Urethral meatal stenosis

25. 排尿障礙治療中心 版權所有 Dysfunctional voiding in woman with UTI, incontinence

26. 排尿障礙治療中心 版權所有 Cystocele with Bladder outlet obstruction

27. 排尿障礙治療中心 版權所有 Nocturnal polyuria and Recurrent UTI Women may have large nocturnal urine volume (>900mL or >33% total volume) and small bladder capacity or lower compliance UTI develops during night time Treatment with antidiuretics (DDAVP) or CISC before bed time

28. 排尿障礙治療中心 版權所有 Recurrent UTI in Children In neonates UTI occurs more commonly in boys (2.7%) than girls (0.7%) In children >1 y/o UTI is 9 times more frequent in girls than boys In asymptomatic children reflux is 1% Reflux is diagnosed in 50% of infants 4 years

29. 排尿障礙治療中心 版權所有 Evaluation of UTI in Children All children regardless of sex and age be examined by ultrasound and VCUG after first UTI Radionuclide cystograpgy is more sensitive to detect VUR in younger child Renal scarring can be detected by ultrasound, IVP, DMSA scintigraphy

30. 排尿障礙治療中心 版權所有 Voiding cystourethrography in Vesicoureteral reflux

31. 排尿障礙治療中心 版權所有 Recurrent UTI or VUR In girls with UTI, 40-60% have symptoms of urgency, frequency, squatting behaviour, and diurnal incontinence. In most girls with VUR, infrequent voids with large volume In boys, frequent small voids in more children with VUR (36%) than healthy boys (15%)

32. 排尿障礙治療中心 版權所有 Vesicoureteral Reflux Primary – A short submucosal tunnel Secondary – Increased bladder pressure due to neuropathic bladder, anatomical abnormality, outlet obstruction At birth the majority of VUR is seen in boys, by age 1 the incidence of VUR is greater in girls Many girls have secondary VUR because of voiding dysfunction

33. 排尿障礙治療中心 版權所有 Dysfunctional voiding in a girl with incontinence & VUR

34. 排尿障礙治療中心 版權所有 Children & Voiding dysfunction External sphincter as a role of UTI Close association of constipation with voiding dysfunction, recurrent UTI and vesicoureteral reflux (dysfunctional elimination syndromes) Non-invasive programs for pelvic floor hypertonicity can successfully treat incontinence, recurrent UTI, reducing surgical intervention for reflux

35. 排尿障礙治療中心 版權所有 Voiding dysfunction and Incontinence in children Detrusor overactivity and/or Pelvic floor dysfunction Anticholinergics and behavioral therapy Diurnal enuresis or nocturnal enuresis Increased fluid intake, time voiding, correction of constipation cured 15-20% of children with voiding dysfunction

36. 排尿障礙治療中心 版權所有 Detrusor overactivity in a boy with urge incontinence

37. 排尿障礙治療中心 版權所有 Dysfunctional voiding & UTI Breakthrough UTI occurs 43% with DV leading to surgery versus 11% without DV VUR resolved spontaneously in 61% of girls with normal voiding and in 45% with DV after receiving antimicrobials and oxybutynin

38. 排尿障礙治療中心 版權所有 Bilateral VUR in a girl with Meningomyelocele

39. 排尿障礙治療中心 版權所有 Resolution of VUR after antibiotics and oxybutynin

40. 排尿障礙治療中心 版權所有 Detrusor instability and VUR 28% unilateral VUR and 78% bilateral VUR have detrusor instability In cases with bilateral VUR 26% failed antireflux surgery Failed surgery for reflux is often associated with voiding dysfunction 70% VUR resolved after anticholinergics

41. 排尿障礙治療中心 版權所有 Detrusor instability & Pelvic floor overactivity Pelvic floor contracts with an uninhibited detrusor contraction Chronic contraction of pelvic floor can cause uninhibited detrusor contractions through collateral innervation Voiding dysfunction associates with constipation Anticholinergics and alpha-adrenergic blocker are effective

42. 排尿障礙治療中心 版權所有 Voiding dysfunction and Pseudodyssynergia Bilateral VUR is a positive predictor for voiding dysfunction In voiding dysfunction with VUR, detrusor instability 55%, large bladder capacity 14%, pseudodyssynergia 30% Managing constipation and voiding dysfunction has the biggest impact on preventing recurrent UTI

43. 排尿障礙治療中心 版權所有 Pelvic Floor Therapy Individually adapted voiding & drinking schedule Pelvic floor relaxation biofeedback Instruction on toilet behaviour Biofeedback uroflowmetry Prophylactic antimicrobials during treatment In 83% girls UTI was effectively treated, in 64% incontinence cured, in 7/8 reflux cured

44. 排尿障礙治療中心 版權所有 Diagnosis of Dysfunctional voiding Uroflowmetry combined with EMG Pressure flow study – high voiding pressure low flow rate and overactive external sphincter EMG during voiding Videourodynamic study- high voiding pressure low flow rate, and a spinning top urethrogram

45. 排尿障礙治療中心 版權所有 Voiding cystourethrography of Dysfunctional voiding

46. 排尿障礙治療中心 版權所有 Videourodynamic study for Dysfunctional voiding

47. 排尿障礙治療中心 版權所有 Factors for Recurrent UTI Low bladder compliance Large residual urine High voiding pressure Pseudodyssynergia Constipation Large bladder capacity and infrequent voids

48. 排尿障礙治療中心 版權所有 Treatment of recurrent UTI in Children Treat constipation,recurrent UTI, voiding dysfunction together Increased fluid intake for constipation Trimethoprim- Sulfamethoxazole is the drug of choice Patients > 4 years pelvic floor retraining Start prophylactic antimicrobial if breakthrough UTI develops

49. 排尿障礙治療中心 版權所有 Genital Tract Infection Acute & chronic prostatitis Acute & chronic epididymitis Should search for urinary tract obstruction such as prostate obstruction, urethral stricture, poor relaxation of urethral sphincter

50. 排尿障礙治療中心 版權所有 Poor relaxation of urethral sphincter In younger population men Severe hesitancy, poor stream, intermittency, residual urine sensation Combined with chronic prostatitis No frequency or nocturia Low voiding pressure low flow urodynamic tracing

51. 排尿障礙治療中心 版權所有 Uroflowmetry in Spastic urethral sphincter

52. 排尿障礙治療中心 版權所有 Low pressure low flow in young man with dysuria

53. 排尿障礙治療中心 版權所有 Reflux Genital infection and Chronic prostatitis

54. 排尿障礙治療中心 版權所有 Postprostatectomy UTI & genital tract infection Residual prostatic obstruction Urethral stricture Poor relaxation of urethral sphincter Low detrusor contractility and large residual urine Presence of diverticulum or VUR