1. 排 尿 障 礙 及 尿 動 力 學 判 讀 新 光 吳 火 獅 紀 念 醫 院 泌 尿 科 葉 忠 信 醫 師

2. What the voiding dysfunction is
Failure to store and/or empty in terms of time and/or place
Disorders of micturition may be classified as storage problems, emptying problems, and combinations of the two

4. SYMPTOMS AND SIGNS Frequency, Urgency, Nocturia
Hesitancy, Weak Stream, Intermittency, Incomplete Emptying
Lower Urinary Tract Symptoms(LUTS)
Urinary Retention
Urinary Incontinence(stress,urge,mixed,overflow,total)
Nocturnal Enuresis(DI, Nocturnal Polyuria, PNE)
Suprapubic pain
Associated symptoms

5. AUA Symptom Index

6. Clinical Comprehensive Evaluation
Bladder Diary
History Taking(DM,Heart D’s,HTN,Renal D’s)
Physical Examination(Prostate, Pelvic, Neurological)
Laboratory exam.(U/A, U/C, Biochemistry, UFM)
X-ray Image(KUB, IVU, VCUG)
Ultrasound(Prostate, Residual Urine, Female B&U)
Cystoscopy(CIS, ISD)
Urodynamic Study(UFM,CMG,EMG,UPP,PFS,LPP, VUDS)
The goal: To clarify the pathophysiolgy of voiding dysfunction

7. Bladder Diary

8. Clinical Comprehensive Evaluation
Bladder Diary
History Taking(DM,Heart D’s,HTN,Renal D’s)
Physical Examination(Prostate, Pelvic, Neurological)
Laboratory exam.(U/A, U/C, Biochemistry, UFM)
X-ray Image(KUB, IVU, VCUG)
Ultrasound(Prostate, Female B&U, Residual Urine)
Cystoscopy(CIS, ISD)
Urodynamic Study(UFM,CMG,EMG,UPP,PFS,LPP, VUDS)
The goal: To clarify the Pathophysiolgy of voiding dysfunction

10. The Significance of Residual Urine
Post-void RU:bladder(B) and outlet(O) relation
Increased RU:B and/or O problems
Negligible RU: normal mechanical function of LUT
Generally, RU increase: relative detrusor failure with or without outlet obstruction.
RU:not correlate with intravesical pressure, poor test-retest reliability
RU with clinical circumstances, providing useful info.
Ultrasound? Or Catheterizatin

11. Clinical Comprehensive Evaluation
Bladder Diary
History Taking(DM,Heart D’s,HTN,Renal D’s)
Physical Examination(Prostate, Pelvic, Neurological)
Laboratory exam.(U/A, U/C, Biochemistry, UFM)
X-ray Image(KUB, IVU, VCUG)
Ultrasound(Prostate, Female B&U, Residual Urine
Cystoscopy(CIS, ISD)
Urodynamic Study(UFM,CMG,EMG,UPP,PFS,LPP, VUDS)
The goal: To clarify the pathophysiolgy of voiding dysfunction

13. Clinical Comprehensive Evaluation
Bladder Diary
History Taking(DM,Heart D’s,HTN,Renal D’s)
Physical Examination(Prostate, Pelvic, Neurological)
Laboratory exam.(U/A, U/C, Biochemistry, UFM)
X-ray Image(KUB, IVU, VCUG)
Ultrasound(Prostate, Female B&U, Residual Urine)
Cystoscopy(CIS, ISD)
Urodynamic Study(UFM,CMG,EMG,UPP,PFS,LPP, VUDS)
The goal:To clarify the pathophysiolgy of voiding dysfunction

15. Application and Interpretation of Urodynamics
The goal : fully understand the pathophysiology underlying voiding dysfunction
The feature : 1) logical extension of the history and physical examination 2) an interactive process between patient and clinician
The pitfalls: 1) human mind, machine, and computer; each is fallible 2) the final diagnosis resides in the clinician’s brain, not CPU of the computer

16. Cystometrogram(CMG) A basic tool ; no CMG, no complete UDS
Vesical pressure as function of bladder volume
“Yes” for capacity, sensations, compliance, contraction
“No” for functional capacity, detrusor’s contractibility, involuntary contraction or not,
Magnitude and duration not properly evaluated without simultaneous uroflow
Gas or fluid
CMG with special test(urecholine, ice-water, KCL test)
Rapid cystometry( Viscoelasticity)

17. CMG

18. CMG
Normal
Normal

19. CMG
Detrusor
Hyperreflexia
Poor Compliance DI

20. CMG
BOO with DI
DHIC

21. CMG
Detrusor Arflexia
Detrusor
Underactivity

22. CMG
Bladder Hypersesitivity

23. Uroflowmetry(UFM) Simple, non-invasive, favorably repeatable
Answer only one question: flow rate and trace itself
Voided volume< ml vs. corrected Qmax
Low flow rate, outlet or detrusor impairment

24. UFM(voided volume)

25. UFM(Qmax)

26. UFM(flow pattern)
Constrictive
Too short time to Qmax
Serrated

27. UFM(flow pattern)
Compressive-outlet
Compressive-Detrusor

28. UFM(flow pattern)
Intermittent

29. Sphincter Electromyography
Answer if sphincter relax or contract during detrusor contraction and voiding
Evidence of neurologic or myopathic lesion or not
Increased EMG activity—contract; decreased—relax
EMG activity not related to the strength of sphincter contraction

30. EMG
Normal
Normal

31. EMG
Artifact

32. EMG
Pseudodyssynergia
with DI

33. EMG
Pseudodyssynergia
Spinning top

34. EMG
Poor relaxation

35. EMG
DESD type1
DESD type2

36. EMG
B-C reflex
DESD type3

37. Urethral Pressure Profile(UPP)
In static UPP, little correlation with any useful clinical information
Stress and micturitional UPP: pressure transmission from abdomen to urethra and the site of pressure changes

38. Stress UPP
SUI

39. UPP for pelvic floor exercise(1)
Effective

40. UPP for pelvic floor exercise(2)
Ineffective

41. Pressure Flow Study(PFS)
The only way determining “Yes or No” of BOO & IBC
A well-designed commode very important for performing this test properly

42. PFS
Pdet.Qmax-2Qmax=AG number

43. PFS
Pitfall 1

44. PFS
Pitfall 2

45. PFS
Pitfall 3
Pitf

46. PFS
Upper tract obstruction?
>22 cmH2O
<15 cmH2O

47. PFS
Obstruction

48. PFS
Non-obstruction

49. PFS
Non-obstruction
Non-reflux

50. PFS
Pitfall!

51. Leak Point Pressure(LPP)
Abdominal leak point pressure(ALPP):The vesical pressure at the time of leakage occurring during a maneuver which increases abdominal pressure
Detrusor leak point pressure(DLPP): The detrusor pressure at the time of leakage responding to an abnormal high urethral resistance
ALPP for measuring stress urinary incontinence
DLPP indicating progressive upper tract changes
ALPP includes VLPP and CLPP( Valsalva, cough LPP)
No detrusor contraction occurred for a real ALPP

52. LPP
High DLPP with bil.hydronephrosis

53. LPP
Valsalva or Cough
Val
Vals

54. LPP
Interplay of ISD and Hypermobility

55. LPP
Intrinsic vs extrinsic

56. LPP
Type 3 SUI

57. LPP
Type 2 SUI

58. LPP
Type 1 SUI

59. Video-urodynamics(VUDS)
The radiographic image plus PFS an EMG
PFS vs VUDS; site of obstruction
More information about bladder and urethra
Expensive? ; need more expertise
The “gold standard” in urodynamics

60. VUDS
BPH with BOO

61. VUDS
Female SUI

62. VUDS
SCI with DESD

63. VUDS
Anterior Urethral Valve

64. VUDS
Spinning Top
Urethral Sphincter Spasm

65. VUDS
Cervical SCI with AD

66. VUDS
PFMT for SUI

67. Acknowledgement The best way to learn is to teach and to present
Many a thank to Professor Kuo for everything
Thank You for Your Attention