排尿障礙治療中心 版權所有 Lower Urinary Tract Symptoms in Women Hann-Chorng Kuo...

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Lower Urinary Tract Symptoms in Women

Hann-Chorng Kuo

Department of Urology

Buddhist Tzu Chi General Hospital

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Female Lower Urinary Tract Symptoms

Storage symptoms

Frequency, Urgency, Nocturia

Incontinence

Suprapubic fullness and painEmpty symptoms

Hesitancy, Intermittency, Small caliber,

Dysuria, Residual urine sensation

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Differential Diagnosis of LUTS in Women

Increased bladder sensationDetrusor overactivity (idiopathic, neurogenic)Detrusor underactivityBladder outlet obstruction Interstitial cystitis and painful bladder syndromePoor relaxation of pelvic floor musclesMixed urinary incontinencePelvic floor relaxation and prolapse

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Voiding Diary

3-day voiding diaryIncluding incontinence episodeUrine amountDrinking amountNocturnal urine amountNocturnal frequency

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Voiding Diary

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Initial Assessment

Abdominal physical examination

Bladder, Operation scarPerineal examination

Cystocele, Rectocele, Uterine prolapse

Urine leakage on cough, fistula

Vaginal mucosa, Vaginal tendernessNeurological examination

B-C Reflex, PFM contractility, Anal tone

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CystoscopySpecific and nonspecific cystitis

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Cystoscopy Irradiation cystitis

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Cystoscopy Bladder cancer

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Sonography of Lower Urinary Tract

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Transrectal LUT Sonography

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TRSB – Urethral anatomy

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TRSB in Continent Woman

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TRSB – Bladder neck incompetence

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Role of External Sphincter in Urgency Frequency Syndrome and Stress Incontinence

Patients NCross-Sectional Area

(mm2)

Smooth Muscle Component

(mm2)

Striated Muscle Component

(mm2)

A.Control 14 96.4 ± 38.4 42.5 ± 18.3 53.9 ± 35.3

B.FUS 37 107.4 ± 34.6 47.4 ± 23.9 59.9 ± 23.9

C.Mild SUI 42 85.2 ± 27.9 41.3 ± 16.1 43.9 ± 20.9

D.Severe SUI 18 90.3 ± 34.9 49.9 ± 23.9 37.8 ± 22.8

Cystocele* (9) 75.7 ± 2301 37.9 ± 12.2 37.8 ± 22.8

Total 111 94.8 ± .3.77 44.9 ± 20.6 49.9 ± 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

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Cystography and Radiology

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Tentative Diagnosis

Acute cystitis- evidence of pyuriaHypersensitive bladder – small voided volume & nor

mal flow patternDetrusor overactivity – urge incontinenceBladder outlet obstruction- low flow rate, obstructiv

e flow pattern, residual urinePelvic floor hypertonicity – intermittent flow Interstitial cystitis – lower abdominal pain at a full bl

adderProlapse and pelvic floor relaxation

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Urodynamic Study

UroflowmetryCystometry Urethral sphincter EMGUrethral pressure profilometryPressure flow multi-channel studyVideourodynamic studyResidual urine volume

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Differential Diagnosis based on Lower urinary tract symptoms

Hypersensitive bladder – normal flow rateOveractive bladder – presence of DIContracted bladder – low bladder complianceSpastic urethral sphincter – low flow rate, large r

esidual urine, poor relaxed sphincter EMG Interstitial cystitis – lower abdominal pain at full

bladder, small capacity, low compliance, positive KCl test

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Normal Uroflowmetry in Taiwanese Women

Age NumberVoided

Volume(ml)

Qmax

(ml/sec)Cqmax

Qmean

(ml/sec)

Flow Time

(sce)

≦ 29 12290.35±84.51

(12)

28.53±6.15

(12)

1.76±0.58

(12)

11.57±5.83

(12)

38.9±35.32

(12)

30-39 39331.08±116.51

(39)

30.22±9.38

(39)

1.73±0.57

(39)

12.17±8.77

(39)

42.46±38.87

(39)

40-49 61319.72±139.13

(60)

28.73±7.63

(60)

1.71±0.51

(60)

12.75±6.31

(60)

28.39±20.48

(60)

50-59 62307.54±156.18

(61)

28.47±11.08

(61)

1.84±1.57

(61)

11.61±6.15

(61)

32.08±22.74

(61)

60-69 40349.66±199.40

(38)

25.68±6.75

(38)

1.46±0.35

(38)

10.86±6.81

(38)

40.25±25.99

(38)

≧ 70 23284.12±141.17

(17)

27.78±10.26

(17)

1.71±0.42

(17)

10.80±4.75

(17)

25.67±14.94

(17)

Regression analysis P=0.7626 P=0.07 P=0.5648 P=0.2382 P=0.2395

Total 237317.19

(227)

283.32±9.10

(227)

1.71±0.92

(227)

11.83±6.76

(227)

34.22±26.91

(227)

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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

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Uroflowmetry – Normal flow

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Uroflowmetry – Low contractility

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Uroflowmetry – Obstructive flow

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Uroflowmetry – Straining flow

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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 measurementProvide fruitful lower urinary tract

information

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Multi-channel Pressure Flow Study

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Urodynamic Parameters in Non-obstructive Taiwanese Women

N Pdet.Qmax QmaxVoided volume

Residuum DI

SUI 26917.0 ± 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 23519.9 ± 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%)

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Pressure flow study – DHIC

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Pressure flow study–Cystocele and BOO in woman

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Low contractility & low flow

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Detrusor instability in Storage phase

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DI in contracted bladder

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SCI & NVD – Type 1 DESD

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Provoked DI in storage phase

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Urethral Pressure Profilometry

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Urethral Pressure Profile in Normal Taiwanese Women

Age NumberMUCP

(cmH2O)

FPL

(cm)

≦ 29 12 90.28±39.43 (7) 2.86±0.44 (7)

30-39 39 81.52±22.78 (21) 2.89±0.47 (21)

40-49 61 72.40±26.95 (29) 2.85±0.59 (29)

50-59 62 66.74±32.16 (28) 2.98±0.83 (28)

60-69 40 63.19±26.09 (21) 2.88±0.66 (21)

≧ 70 23 53.36±26.13 (8) 2.71±0.59 (8)

Regression analysis P=0.0010 P=0.8279

Total 237 70.75±29.80 (114) 2.89±0.65 (114)

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Stress UPP in Incontinent woman

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Nitric oxide UPP in Neuropathic bladder

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Voluntary Pelvic floor contraction

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Differential Diagnosis of Urinary Incontinence

Genuine stress incontinenceDetrusor overactivity incontinenceMixed stress and urge incontinenceNeurogenic detrusor overactivity incontine

nceIntrinsic sphincteric deficiencyChronic retention & incontinence

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Abdominal Leak point pressure in Type I GSI

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Cough vs Valsalva LPP in Type II/III SUI

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Cough vs Valsalva LPP in Pure Type III SUI

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CVA and Detrusor overactivity incontinence

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Poor compliant bladder and Stress urinary incontinence

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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

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Bladder Neck Dysfunction in Female BOO

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Videourodynamic study in Female urethral stricture

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Videourodynamic study in Female urethral stricture

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Poor relaxation of urethral sphincter

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Low pressure and BOO

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Dysfunctional voiding in woman with urge incontinence

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Comparison of Qmax in BOO and Non-obstructive Women

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Comparison of Voiding Pressure in Women with BOO

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Nomogram of Pressure flow Plot in Women with BOO

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No-pathological Conditions

Habitual frequency and urgencyHyperosmolar diuresisNocturnal polyuriaPolydipsiaDiuretic medication Conditional reflex ?

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Treatment options- Medical Treatment

Alpha-blockerAnticholinergic drugsSkeletal muscle relaxantAdrenergic agonistDDAVPEstrogen replacementBotulinum toxin

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Efficacy of DDAVP in Nocturnal polyuria

Baseline Posttreatment

P Value

(Paired t Test)

Nocturjal frequency

(times/night)5.20 ± 1.16 2.24 ± 1.12 <0.0001

Noctunal urine volume

(mL)955.6 ± 255.9

522.8 ± 210.5

<0.0001

Quality of life 4.47 ± 1.07 1.05 ± 0.91 <0.0001

Urine specific gravity1.012 ± 0.007 1.016 ± 0.00

50.011

Serum sodium (mEq/L)139.5 ± 4.34

139.7 ± 3.84 0.761

Serum Potassium (mEq/L)

4.46 ± 0.35 4.31 ± 0.44 0.022

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Intravesical Therapy

DitropanCapsaicin- 1mM for DH, 1uM for HSB Resiniferatoxin- 1uM for DH, 10nM HSBHeparin- for ICDMSO- for ICXylocaine

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Resiniferatoxin Intravesical Therapy for detrusor overactivity

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Heparin Intravesical Therapy for Urothelial Leak Syndrome

Baseline 3 mo p value

FSF (mL) 96.5 ± 46.4 146.1 ± 55.4 0.001

US (mL) 225.4 ± 96.2 264.9 ± 84.2 0.009

Cystometric capacity (mL) 262.0 ± 89.8 304.3 ± 84.8 0.002

Pdet Qmax (cmH2O) 25.7 ± 9.1 28.3 ± 9.3 0.070

Qmax (mL/sec) 12.9 ± 5.7 15.1 ± 7.7 0.063

Residual urine (mL) 29.4 ± 38.4 14.5 ± 25.7 0.096

IPSS (points) 19.5 ± 4.6 9.0 ± 4.0 0.000

Nocturia (times/might) 5.7 ± 2.0 2.3 ± 1.1 0.000

Pain scale of KCl (points) 3.2 ± 0.5 0.7 ± 0.7 0.000FSF = first sensation of filling; US = urge sensation; Pedt Qmax = detrusor pressure at maximal flow rate; Qmax = maximal flow rate; IPSS = International Prostate Symptom Score.

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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 (?)

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Urethral Pressure Profile before and after Botulinum toxin injection

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Urethral Dilataion

Effective for urethral strictureEffective for dysfunctional voiding when

combined with estrogen therapyIneffective if severe bladder neck scarringPsychogenic effect ?

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Physical Therapy

Pelvic floor muscle exerciseBiofeedbackElectrical stimulationSacral root stimulationElectromagnetic current

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Surgical Treatment

Sling procedure – urethral incontinenceTUI-Bladder neck – bladder neck dysfunct

ion, Idiopathic BN obstructionCystoscopic hydrodilatationEnterocystoplasty- severe IC