1. 排尿障礙治療中心 版權所有 The Role of Urodynamics in 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 Urodynamics Investigation of bladder and urethral function in filling and voiding phases Confirmation of clinical diagnosis Provide evidence for selection of therapeutic modalities Follow-up patients with unexpected therapeutic results

3. 排尿障礙治療中心 版權所有 Urodynamics and Stress Urinary Incontinence Detection of detrusor overactivity in patients with SUI Differentiate types of SUI Analysis of underlying pathophysiology of SUI Selection of surgical procedure for SUI Postoperative follow-up in patients with LUTS and de novo urge

4. 排尿障礙治療中心 版權所有 Role of Uroflowmetry and Postvoid residual urine in SUI A high Qmax with little PVR usually indicate normal detrusor contractility A low Qmax with straining pattern may imply poor relaxing urethral sphincter or low detrusor contractility Large residual urine indicates inadequate voiding efficiency Flow pattern is important in bladder function

5. 排尿障礙治療中心 版權所有 Isolated sphincter obstruction after radical hysterectomy

6. 排尿障礙治療中心 版權所有 Large cystocele and bladder outlet obstruction

7. 排尿障礙治療中心 版權所有

8. Role of Urethral pressure profile in SUI Academic interest High false negative stress test rate A positive test simply imply existence of anatomical SUI A low MUCP may indicate the existence of intrinsic sphincter deficiency (20 cm water by microtip method, 60 cm water by perfusion method)

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

10. 排尿障礙治療中心 版權所有 Changes of maximal urethral closure pressure with age 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)

11. 排尿障礙治療中心 版權所有 Role of Cystometry in SUI Bladder capacity Bladder compliance Detrusor overactivity Detrusor contractility

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

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

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

15. 排尿障礙治療中心 版權所有 Diagnosis of Lower Urinary Tract Dysfunction in SUI Poor compliant bladder with SUI – after radical hysterectomy Detrusor overactivity with SUI– Stroke, Parkinson’s disease Detrusor underactivity with SUI – Diabetes mellitus, peripheral neuropathy Contracted bladder with SUI

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

17. 排尿障礙治療中心 版權所有 Poor bladder compliance with low urethral resistance

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

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

20. 排尿障礙治療中心 版權所有 Pressure flow study Important urodynamic test for SUI Abnormal P/F results include low pressure low flow, high pressure low flow BOO, acontractile bladder,non-relaxing urethral sphincter Residual urine volume Sphincter EMG coordination

21. 排尿障礙治療中心 版權所有 Normal bladder compliance with low urethral resistance and SUI

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

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

24. 排尿障礙治療中心 版權所有 Leak Point Pressure measurement Detrusor LPP Abdominal LPP Valsalva LPP Cough LPP Difference in CLPP and VLPP Clinical significance in CLPP and VLPP

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

26. 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

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

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

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

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

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

32. 排尿障礙治療中心 版權所有 Relationship of MUCP and Leak-point pressures A low MUCP is significantly correlated with a low LPP Patients with a low MUCP may raise suspicion of intrinsic sphincter deficiency Patients with high grade cystocele may have a high LPP but MUCP remains low in existence of ISD

33. 排尿障礙治療中心 版權所有 Relationship of LPP, BN Descent and Grade of SUI Grade 1 SUI (n= 47) Grade 2 SUI (n= 41) Grade 3 SUI (n= 28) Statistics P value CLPP (cm H 2 O)135.8 ± 30.9110.0 ± 26.790.6 ± 36.70.000 VLPP (cm H 2 O)107.2 ± 32.965.8 ± 22.450.5 ± 31.10.000 BN descent at CLPP (cm) 1.149 ± 0.650 0.976 ± 0.642 0.589 ± 0.5620.001 BN descent at VLPP (cm) 1.383 ± 0.802 1.098 ± 0.700 0.679 ± 0.6700.001 Mean ± standard deviation, SUI=stress urinary incontinence, CLPP= cough leak point pressure, VLPP= Valsalva leak point pressure, BN= bladder neck

34. 排尿障礙治療中心 版權所有 Relationship of CLPP, VLPP and BN Descent VLPP <60 (n= 41) 60<VLPP<90 (n= 36) VLPP >90 (n= 39) Total CLPP=VLPP BN < 1.0 cm 3 (7.3%)1 (2.8%)1 (2.6%)5 (4.3%) CLPP=VLPP BN > 1.0 cm 02 (5.6%)8 (20.5%)10 (8.6%) CLPP>VLPP BN < 1.0 cm 22 (53.6%)7 (19.4%)6 (15.4%)35 (30.2%) CLPP>VLPP BN > 1.0 cm 16 (39%)26 (72.2%)24 (61.5%)66 (56.9%) Total413639116

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

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

37. 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

38. 排尿障礙治療中心 版權所有 Videourodynamic study & SUI Thorough examination of bladder and urethral anatomy & function Accurate measurement of leak-point pressure Provide patient’s education

39. 排尿障礙治療中心 版權所有 Bladder neck Incompetence in SUI Urethrovesical facilitative reflex may exist in women with an incompetent bladder neck Adequate bladder neck suspension to close the bladder neck and prevent persistent postoperative urge A BN incompetence may associate higher grade SUI

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

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

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

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

44. 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

45. 排尿障礙治療中心 版權所有 Videourodynamics in Evaluation of PFMT Determine abdominal leak point pressure Measure bladder base descent during straining Measure bladder base elevation during PME Educate patient to perform an effective PME

46. 排尿障礙治療中心 版權所有 Predictive Factors for a Successful Physiotherapy Low patient age and presence of estrogen Absence of detrusor instability Absence of intrinsic sphincteric deficiency Low urethral hypermobility Good compliance with treatment

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

48. 排尿障礙治療中心 版權所有

50. Low PTR and good pelvic floor contraction pressure

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

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

53. 排尿障礙治療中心 版權所有 The Urodynamic Parameters after Pelvic Floor Muscle Training (I) Pre- treatment Post-treatmentStatistics (p value) Qmax (mL/s)Total22.6 ± 13.020.9 ± 10.20.390 Successful26.0 ± 10.7723.4 ± 10.70.236 Failure18.3 ± 14.917.8 ± 9.20.881 Voided volumeTotal 340.5 ± 123.4 386.1 ± 152.90.240 Successful395.4 ± 69.8414.1 ± 176.30.780 Failure 273.3 ± 144.5 351.9 ± 119.40.021 FSF (mL)Total101.0 ± 26.8128.2 ± 41.60.025 Successful96.1 ± 21.1136.4 ± 45.80.027 Failure107.0 ± 32.7118.1 ± 35.70.484 FS (mL)Total189.0 ± 47.5229.5 ± 46.90.006 Successful190.4 ± 51.4245.0 ± 47.40.015 Failure187.3 ± 45.2210.4 ± 40.90.218

54. 排尿障礙治療中心 版權所有 The Urodynamic Parameters after Pelvic Floor Muscle Training (II) Pre-treatmentPost-treatmentStatistics (p value) Cystometric Capacity (mL) Total288.2 ± 83.8338.0 ± 96.10.050 Successful303.0 ± 82.9377.8 ± 100.60.086 Failure270.1 ± 86.0289.3 ± 66.80.376 Compliance (mL / cmH 2 O) Total63.8 ± 69.7138.3 ±170.30.069 Successful58.7 ± 53.0190.4 ± 208.00.045 Failure70.0 ± 89.174.7 ± 80.40.914 Pdet (cmH 2 O)Total22.5 ± 9.021.9 ± 10.30.777 Successful21.5 ± 8.918.3 ± 8.30.328 Failure23.8 ± 9.526.2 ± 11.30.465 LPP(cmH 2 O)Total111.7 ± 43.9113.9 ± 20.70,816 Successful122.3 ± 44.9109.3 ± 23.30.518 Failure99.6 ± 42.8119.3 ± 17.40.233

55. 排尿障礙治療中心 版權所有 The Urodynamic Parameters after Pelvic Floor Muscle Training (III) Pre-treatmentPost-treatmentStatistics (p value) MUCP (cmH 2 O) Total75.4 ± 30.270.5 ± 23.90.304 Successful72.5 ± 24.376.9 ± 23.60.393 Failure78.9 ± 37.562.7 ± 23.30.047 FPL (mm)Total34.5 ± 4.5936.6 ± 4.90.300 Successful34.4 ± 4.936.3 ± 5.10.089 Failure34.8 ± 4.436.9 ± 5.00.198 PTR (%)Total47.9 ± 15.150.8 ± 10.20.486 Successful51.6 ± 17.450.2 ± 9.90.847 Failure43.4 ± 11.151.7 ± 11.10.049 PFC (cmH 2 O)Total15.7 ± 13.423.0 ± 22.20.043 Successful20.5 ± 12.536.0 ± 21.20.009 Failure9.9 ± 12.77.1 ± 9.60.051

56. 排尿障礙治療中心 版權所有

58. The Urodynamic Parameter after Pelvic Floor Muscle Training ( Ⅳ ) Pre-treatmentPost-treatmentStatistics (p value) Resting BN position (cm) Total1.40 ± 0.741.65 ± 1.130.304 Successful1.14 ± 0.951.54 ± 1.210.213 Failure1.72 ± 1.201.77 ± 1.060.886 Straining BN position (cm) Total2.79 ± 1.782.29 ± 1.470.138 Successful2.55 ± 1.562.18 ± 1.530.372 Failure3.13 ± 2.122.44 ± 1.450.270 BN descent (cm) Total1.45 ± 1.010.68 ± 0.490.000 Successful1.31 ± 1.190.59 ± 0.370.031 Failure1.61 ± 0.780.78 ± 0.620.004 BN elevated PFMT (cm) Total0.83 ± 0.491.40 ± 0.740.000 Successful1.14 ± 0.321.91 ± 0.440.000 Failure0.44 ± 0.390.78 ± 0.510.022

59. 排尿障礙治療中心 版權所有

61. Cystometry biofeedback for urge incontinence For women who failed electrical stimulation, were intolerant to anticholinergics, Urodynamic detrusor overactivity was proven Performed several voluntary PFMC at episodes of DI while watching CMG tracing and EMG activity Try to inhibit urge incontinence as longer duration as possible at home

62. 排尿障礙治療中心 版權所有 Detrusor overactivity and CMG biofeedback

63. 排尿障礙治療中心 版權所有 Biofeedback to inhibit detrusor instability

64. 排尿障礙治療中心 版權所有 Postoperative follow-up of LUTS Frequency urgency – persistent bladder neck incompetence Urge incontinence – bladder outlet obstruction Difficult urination – bladder outlet obstruction, bladder hypersensitivity Stress incontinence – inadequate urethral resistance, existence of type III SUI

65. 排尿障礙治療中心 版權所有 Urodynamic results after pubovaginal sling procedure Mean ( SD ) variableA ( before )B (at 7 days )C (at 3 months )P<0.05 Q max (mL/s) 13.0(7.3)13.1(6.5)17.5(5.7)A vs C,B vs C Capacity (mL) 275(113)253(61.32)269(67.1)NS P det (cmH 2 O) 20.3(10.5)21.9(10.3)21.3(7.1)NS BN opening time (s) 8.5(8.1)24.3(27.1)12.1(10.3)A vs B Residual vol. (mL) 47.9(53.7)38.5(62.1)15.7(23.9)NS

66. 排尿障礙治療中心 版權所有 Videourodynamic results after Pubovaginal sling procedure

67. 排尿障礙治療中心 版權所有 Selection of Treatment modality for SUI by Urodynamics Type I – behavioral therapy, pelvic floor muscle exercises Type II – pelvic floor exercises, anterior colporrhaphy, pubovaginal sling procedure Type II/III – pubovaginal sling procedure at proximal urethra Type III – pubovaginal sling at mid-urethra, urethral collagen injection

68. 排尿障礙治療中心 版權所有 Long term (5-year) results of Anti-incontinence surgery n (a)Gittes BNS (n=62) (b)Raz BNS (n=53) (c)Pubovagin al sling(n=42) Statistics n%n%n% Dry602540.31222.62354.8(a)vs.(b)p<0.05 Improved612032.32547.21638.1(b)vs.(c)p<0.05 Success rate4572.63769.83992.9(a)vs.(c)p<0.05 Moderate SUI211117.7817.024.8(b)vs.(c)p<0.05 Severe SUI1569.7815.112.3

69. 排尿障礙治療中心 版權所有 Success rates of SUI in Different surgical procedures n (a)Gittes BNS (n=62) n (b)Raz BNS (n=53) (c)Pubovagina l sling(n=42) Statistics n%n%n% Type I SUI128/1080.02/2100.0 Type II SUI11132/4178.033/4770.223/23100.0nonsignificant Type III SUI 345/1145.52/450.016/1984.2(a)vs.(c)P<0.05 (b)vs.(c)P<0.05

70. 排尿障礙治療中心 版權所有 Videourodynamics in Post- incontinence surgery & BOO

71. 排尿障礙治療中心 版權所有 Iatrogenic urethral obstruction

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

73. 排尿障礙治療中心 版權所有 Transrectal sonography after PVS Incompetent Bladder Neck Symphysis pubis Urethra * * Sling B A Bladder Neck Urethra Preoperative Postoperative Symphysis pubis