1. 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

2. 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

3. 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

4. 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

5. 排尿障礙治療中心 版權所有 Voiding Diary

6. 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

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

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

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

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

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

12. 排尿障礙治療中心 版權所有 TRSB – Urethral anatomy

13. 排尿障礙治療中心 版權所有 TRSB in Continent Woman

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

15. 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 1496.4 ± 38.442.5 ± 18.353.9 ± 35.3 B.FUS 37107.4 ± 34.647.4 ± 23.959.9 ± 23.9 C.Mild SUI 4285.2 ± 27.941.3 ± 16.143.9 ± 20.9 D.Severe SUI 1890.3 ± 34.949.9 ± 23.937.8 ± 22.8 Cystocele* (9)75.7 ± 230137.9 ± 12.237.8 ± 22.8 Total 11194.8 ±.3.7744.9 ± 20.649.9 ± 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

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

17. 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

18. 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

19. 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

20. 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) ≦ 29 12 290.35±84.51 (12) 28.53±6.15 (12) 1.76±0.58 (12) 11.57±5.83 (12) 38.9±35.32 (12) 30-3939 331.08±116.51 (39) 30.22±9.38 (39) 1.73±0.57 (39) 12.17±8.77 (39) 42.46±38.87 (39) 40-4961 319.72±139.13 (60) 28.73±7.63 (60) 1.71±0.51 (60) 12.75±6.31 (60) 28.39±20.48 (60) 50-5962 307.54±156.18 (61) 28.47±11.08 (61) 1.84±1.57 (61) 11.61±6.15 (61) 32.08±22.74 (61) 60-6940 349.66±199.40 (38) 25.68±6.75 (38) 1.46±0.35 (38) 10.86±6.81 (38) 40.25±25.99 (38) ≧ 70 23 284.12±141.17 (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=0.2395 Total237 317.19 (227) 283.32±9.10 (227) 1.71±0.92 (227) 11.83±6.76 (227) 34.22±26.91 (227)

21. 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

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

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

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

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

26. 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

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

28. 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 269 17.0 ± 7.0 (16.16,17.84) 19.6 ± 8.1 (18.6,20.55) 340.5 ± 115.3 (326.6,354.29) 20.2 ± 26.9 (17.01,23.48) 36 (13.4%) LUTS 235 19.9 ± 7.1 (19.01,20.83) 17.1 ± 7.7 (16.1,18.11) 303.0 ± 122.1 (287.3,318.69) 22.0 ± 32.3 (17.87,26.17) 60 (25.5%)

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

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

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

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

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

34. 排尿障礙治療中心 版權所有 SCI & NVD – Type 1 DESD

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

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

37. 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) ≦ 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)

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

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

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

41. 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

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

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

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

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

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

47. 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

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

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

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

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

52. 排尿障礙治療中心 版權所有 Low pressure and BOO

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

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

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

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

57. 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 ?

58. 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

59. 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 ± 1.162.24 ± 1.12<0.0001 Noctunal urine volume (mL) 955.6 ± 255.9 522.8 ± 210.5 <0.0001 Quality of life 4.47 ± 1.071.05 ± 0.91<0.0001 Urine specific gravity 1.012 ± 0.007 1.016 ± 0.005 0.011 Serum sodium (mEq/L) 139.5 ± 4.34 139.7 ± 3.840.761 Serum Potassium (mEq/L) 4.46 ± 0.354.31 ± 0.440.022

60. 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

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

62. 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 ± 46.4146.1 ± 55.40.001 US (mL)225.4 ± 96.2264.9 ± 84.20.009 Cystometric capacity (mL)262.0 ± 89.8304.3 ± 84.80.002 Pdet Qmax (cmH 2 O)25.7 ± 9.128.3 ± 9.30.070 Qmax (mL/sec)12.9 ± 5.715.1 ± 7.70.063 Residual urine (mL)29.4 ± 38.414.5 ± 25.70.096 IPSS (points)19.5 ± 4.69.0 ± 4.00.000 Nocturia (times/might)5.7 ± 2.02.3 ± 1.10.000 Pain scale of KCl (points)3.2 ± 0.50.7 ± 0.70.000 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.

63. 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 (?)

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

65. 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 ?

66. 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

67. 排尿障礙治療中心 版權所有

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