1. 排尿障礙治療中心 版權所有 Geriatric Incontinence and Nocturnal polyuria Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

2. 排尿障礙治療中心 版權所有 Lower urinary tract symptoms in geriatric population LUTS are common in elderly Nocturia is the third most bothersome LUTS Prevalence of nocturia increases to 80% in patients aged over 80 years Nocturia is one of the most common causes of disturbed sleep pattern

3. 排尿障礙治療中心 版權所有 Prevalence of Male Urinary Symptoms Age group (years) Symptom40-4950-5960-69 ≧ 70 years ≧ 70 years Number800612436271 Percentage reporting: Dribble37434436 Hesitancy14182019 Intermittency18252932 Urgency28324246 Weak stream 25343949 Incomplete emptying 161723 Urge incontinence ---- Burning5647 Nocturia ≧ twice/night 16294255 Frequency > 2/h 34 3635

4. 排尿障礙治療中心 版權所有 Prevalence of Female LUTS Age group (years) Symptom19-3940-5960-79 ≧ 80 Number532838585119 Percentage reporting: Nocturia ≧ 2/night 9132851 Urgency53656268 Urge incontinence 32524859 Hesitancy33221726 Nocturnal enuresis 46417 Poor stream 11182341 Incomplete void 474636

5. 排尿障礙治療中心 版權所有 Bothersomeness of LUTS

6. 排尿障礙治療中心 版權所有 Voiding Diary Assessment of frequency, urgency, and nocturia in patients with LUTS Record voided urine volume and total daily urine volume Calculate nocturnal urine volume Investigate causes for frequency and polyuria

7. 排尿障礙治療中心 版權所有 Hypersensitive bladder with small functional capacity 排 尿 記 錄 單 姓名： 王進輝 病歷號碼： U100009234 日期（第一天）ˍ 9 ˍ月ˍ 2 ˍ日日期（第二天）ˍ 9 ˍ月ˍ 3 ˍ日日期（第三天）ˍ 9 ˍ月ˍ 4 ˍ日 時間尿量喝水量急尿感漏尿時間尿量喝水量急尿感漏尿時間尿量喝水量急尿感漏尿 7-8 150500 7-8 200 500 7-8 250 500 8-9 100 8-9 9-10 150 9-10 150 9-10 200 10-11 90 10-11 250 10-11 200 11-12 200 11-12 12-1 100200 12-1 200 12-1 150 200 1-2 200 1-2 2-3 100 200 2-3 150 3-4 250 4-5 120250 4-5 150 250 4-5 5-6 150 6-7 150 250 6-7 250 6-7 250 7-8 150 7-8 8-9 120 200 8-9 9-10 200 250 10-11 90 10-11 100 10-11 11-12 150 睡 眠 cc/ 次 100/2 次 睡 眠 cc/ 次 150/1 次 睡 眠 cc/ 次 200/2 次

8. 排尿障礙治療中心 版權所有 Normal functional capacity and nocturnal polyuria 排 尿 記 錄 單 姓名： 施冠慨 病歷號碼： U100016284 日期（第一天）ˍ 8 ˍ月ˍ 29 ˍ日日期（第二天）ˍ 8 ˍ月ˍ 30 ˍ日日期（第三天）ˍ 8 ˍ月ˍ 31 ˍ日 時間尿量喝水量急尿感漏尿時間尿量喝水量急尿感漏尿時間尿量喝水量急尿感漏尿 7-8 300 7-8 300 7-8 300 8-9 300 8-9 100 300 8-9 300 9-10 300 9-10 10-11 300 10-11 11-12 100 300 11-12 100 11-12 200 12-1 300 12-1 300 12-1 500 1-2 100 1-2 100 2-3 200 2-3 3-4 300 3-4 4-5 5-6 300 6-7 200 300 6-7 300 6-7 100 7-8 200 100 7-8 8-9 100 8-9 100 300 9-10 10-11 11-12 睡 眠 cc/ 次 700, 600 500,150 4 次 睡 眠 cc/ 次 500,400 2 次 睡 眠 cc/ 次 200,900 350 3 次

9. 排尿障礙治療中心 版權所有 Daytime frequency and Nocturnal polyuria 排 尿 記 錄 單 姓名： 連信雄 病歷號碼： U100036348 日期（第一天）ˍ 8 ˍ月ˍ 19 ˍ日日期（第二天）ˍ 8 ˍ月ˍ 20 ˍ日日期（第三天）ˍ 8 ˍ月ˍ 21 ˍ日 時間尿量喝水量急尿感漏尿時間尿量喝水量急尿感漏尿時間尿量喝水量急尿感漏尿 7-8 1000 7-8 100 1200 7-8 900 8-9 200 8-9 220 9-10 200 9-10 200 9-10 200 150 10-11 100 10-11 100 150 10-11 11-12 100 11-12 150 11-12 200 12-1 100200 12-1 150 300 12-1 200 1-2 150 1-2 2-3 150 2-3 200 2-3 200 3-4 120 3-4 4-5 100150 4-5 120 5-6 100 5-6 120 5-6 6-7 100 150 6-7 300 6-7 100300 7-8 7-8 150 8-9 300 8-9 230 8-9 200 9-10 200 100 9-10 200 9-10 100 150 10-11 100 11-12 210 200 11-12 睡 眠 cc/ 次 300, 300 400 350 睡 眠 cc/ 次 400,480 220 350 睡 眠 cc/ 次 400,400 440

10. 排尿障礙治療中心 版權所有 Polydipsia, Nocturnal polyuria, Small functional capacity 排 尿 記 錄 單 姓名： 李特民 病歷號碼： B100338896 日期（第一天）ˍ 9 ˍ月ˍ 14 ˍ日日期（第二天）ˍ 9 ˍ月ˍ 15 ˍ日日期（第三天）ˍ 9 ˍ月ˍ 16 ˍ日 時間尿量喝水量急尿感漏尿時間尿量喝水量急尿感漏尿時間尿量喝水量急尿感漏尿 7-8 100,800 230 2 7-8 120,80,50 230 3 7-8 80,100,50 230 3 8-9 100,70,80 460 3 8-9 100,100,80 460 3 8-9 100,80,60 460 3 9-10 100,100 230 2 9-10100,50 230 2 9-1050,100 230 2 10-11 120,90 230 2 10-11120,70 230 2 10-11 100,70 230 2 11-12 180,100 120 230 3 11-12100,80 230 2 11-1280,100 230 2 12-1150,80,100 230 3 12-1 180,100, 80 230 3 12-1 80,100,120 230 3 1-2 100,110 230 2 1-2180,100,80 230 2 1-2 80,100 230 2 2-3 100,120 230 2 2-3 100,150 230 2 2-3100,120 230 2 3-480,100,80 230 3 3-4 100,80,50 230 3 3-480,100,60 230 3 4-5 100,80 230 2 4-5 80,90 230 2 4-590,100 230 2 5-6 80,120 230 2 5-6150,80 230 2 5-6 80,120 230 2 6-7 100,80, 100 460 3 6-7 80,120,50 460 3 6-7 100,80,60 230 3 7-8 100,100 230 2 7-8 100,80 230 2 7-8 100,80 230 2 8-9 80,100 230 2 8-9100,120 230 2 8-960,120 230 2 9-10100,50,150 460 4 9-10 150,120,80 460 3 9-10 100,80,120 460 3 10-11 11-12 睡 眠 cc/ 次 1400/7 次 睡 眠 cc/ 次 1300/6 次 睡 眠 cc/ 次 1300/6 次

11. 排尿障礙治療中心 版權所有 Incontinence Detruror instability Urethral incompetence Mixed detrusor instability and urethral incompetence (DHIC) Low bladder compliance Detrusor underactivity and overflow Bladder outlet obstruction

12. 排尿障礙治療中心 版權所有 Detrusr overactivity in elderly Unknown etiology Increased incidence with age May relate with poor cortical perfusion Bladder outlet obstruction in men and women should be considered Urethral relaxation in women Frequency urgency and/or urge incontinence

13. 排尿障礙治療中心 版權所有 Detrusor Overactivity & Pseudodyssynergia after Stroke

14. 排尿障礙治療中心 版權所有 Detrusor overactivity in senile dementia

15. 排尿障礙治療中心 版權所有 Detrusor instability & BPH Asymptomatic BPH may result in detrusor changes with ageing A low Qmax is frequently encountered in the elderly Patients may have frequency urgency but not difficult urination Small functional capacity in BPH

16. 排尿障礙治療中心 版權所有 BPH with Detrusor overactivity

17. 排尿障礙治療中心 版權所有 Low Bladder Compliance and Low contractility

18. 排尿障礙治療中心 版權所有 Poor cortical perfusion & Detrusor overactivity Senile dementia Multiple strokes Post-intracranial hemorrhage Chronic illness in systemic disease and increased incidence of incontinence Schizophrenia and cortical dysfunction

19. 排尿障礙治療中心 版權所有 Low detrusor contractility and low urethral resistance

20. 排尿障礙治療中心 版權所有 Geriatric Incontinence Poor cortical perfusion Sequale of previous stroke Parkinson ’ s disease Benign prostatic obstruction Weak urethral striated sphincter Loss of cortical arousal of bladder fullness

21. 排尿障礙治療中心 版權所有 Detrusor overactivity in woman with ISD

22. 排尿障礙治療中心 版權所有 Dysfuncional voiding with Detrusor overactivity

23. 排尿障礙治療中心 版權所有 Postprostatectomy incontinence Detrusor overactivity not relieved after TURP Intrinsic sphincteric insufficiency Newly developed detrusor overactivity Poor cortical function with ageing Urinary tract infection in non-ISD postprostatectomy men Neurological lesions

24. 排尿障礙治療中心 版權所有 Postprostatectomy incontinence due to urethral incompetence

25. 排尿障礙治療中心 版權所有 Detrusor overactivity in Post- TURP patient

26. 排尿障礙治療中心 版權所有 Transient incontinence (Diappers) Delirium Infection Atrophic vaginitis Psychological disorders Pharmacological effects Excessive urine output Restricted motility Stool impaction

27. 排尿障礙治療中心 版權所有 Management of Geriatric Incontinence Medical treatment: anticholinergics (Ditropan, Detrustol, Tofranil, etc.) On diaper or external appliance On Foley catheter or cystostomy Intravesical resiniferatoxin therapy Detrusor injection of botulinum toxin Surgical treatment

28. 排尿障礙治療中心 版權所有 Anticholinergics Effectively reduced intravesical pressure and contractility Increased postvoid residual urine and possible urinary retention Increased risk of UTI and upper tract deterioration Adverse effects of dry mouth, constipation, blurred vision, weakness

29. 排尿障礙治療中心 版權所有 Diaper and external appliance Suitable for patients with detrusor overactivity and low urethral resistance Not indicated in patients with low detrusor contractility and large PVR Perineal eczema and cutaneous infection including candidiasis Prepuce erosion and urethral injury Frequent change of diaper and external appliance is needed

30. 排尿障礙治療中心 版權所有 Urethral Foley catheterization or Suprapubic cystostomy Active hydration Regular change of catheter Acidic solution irrigation of bladder Intermittent antibiotics for turbid urine or hematuria Prevention of genital tract infection in men, such as vasectomy Prevent fecal soiling in women

31. 排尿障礙治療中心 版權所有 Intravesical resiniferatoxin therapy 10 -7 M RTX bladder instillation Effective in spinal cord lesion induced detrusor hyperreflexia Less effective in non-traumatic neurogenic detrusor overactivity May be effective in detrusor overactivity due to bladder outlet obstruction Low detrusor contractility may occur after high concentrations RTX instillation

32. 排尿障礙治療中心 版權所有 Intravesical RTX therapy for DI

33. 排尿障礙治療中心 版權所有 Botulinum A toxin Detrusor injection Effectively reduced detrusor overactivity and detrusor contractility via blocking Ach release Large residual urine may occur after 300 U botulinum toxin (Botox) injection Periodic injection is needed Not clinical applicable so far

34. 排尿障礙治療中心 版權所有 Response of Botulinum A toxin Detrusor injection in DH

35. 排尿障礙治療中心 版權所有 Nocturia A result of excessive amount of urine production at night Noctural polyuria >35% daily urine Abnormal lower urinary tract function A combination of two etiologies

36. 排尿障礙治療中心 版權所有 Definition of Assessing Nocturia VariableDefinition Nocturnal urine volume (NUV) Nightly voided volume plus first morning Functional bladder capacity (FBC) Largest single recorded voided volume from 24 h voiding diary Nocturia index (NI)NUV/FBC Actual number of nightly voids (ANV)Recorded from voiding diary Predicted number of nightly voids (PNV) NI-1 (rounded to next highest integer if this is not a whole number) Nocturnal bladder capacity index (NBCI) ANV-PNV: if PNV>ANV then NBCI=0 Nocturnal polyuria index (NPI) NUV/24-h total voided volume:Normal<35%

37. 排尿障礙治療中心 版權所有 Voiding Diary Analysis of Nocturia Males(N=65)Females(n=129)BPH(n=15)UI(n=8)SUI(n=25)DI(n=52) NP (n=13) 5% (3)8% (10)0% (0)25% (2)16% (4)13% (7) NDO (n=111) 48% (3)62% (80)33% (5)25% (2)56% (14)54% (28) Mixed (n=70) 48% (31)30% (39)67% (10)50% (4)28% (7)33% (17) NP/Mxd (n=83) 52% (34)38% (49)67% (10)75% (6)44% (11)46% (24) Poly (n=45) 34% (22)18% (23)27% (4)13% (1)8% (2)14% (7)

38. 排尿障礙治療中心 版權所有 Causes of Nocturnal Polyuria CauseUnderlying cause Poor sleep pattern Mental or physical ill health LUT dysfunction Incomplete voiding BOO Detrusor under-activity Bladder overactivity Bladder hypersensitivity Excessive fluid output Primary polydipsia Drugs; diuretics, alcohol, caffeine Circadian changes to arginine vasopressin secretion Diabetes insipidus, melitus Hypercalcaemia

39. 排尿障礙治療中心 版權所有 Homeostatic Controls of Urine Output Intravascular volume and pressure (e.g. heart failure; diuretics; oedema; hypoalbuminaemia) Renal perfusion (e.g. hypertension; chronic renal failure) Serum osmolality (e.g. diabetes mellitus; diabetes insipidus) Thirst mechanism and responsiveness Excessive fluid intake (e.g. psychogenic; caffeine; alcohol) Ability to access fluids (e.g. sedation; ADL status) Levels of circulating hormones and end organ responsiveness Renin (posture; fluid status; drugs) Aldosterone (hypertension; heart failure) Angiotensin Ⅱ (diuretics; ACE inhibitors) Catecholamines Atrial natriuretic peptide (ANP)(heart failure) Arginine vasopressin (AVP) (neurogenic DI; nephrogenic DI) Ageing brain losing its circadian rhythm

40. 排尿障礙治療中心 版權所有 Desmopressin The circardian rhythm of vasopressin was lost in the elderly with nocturnal polyuria Atrial natriureteric peptide in the elderly was higher during night time Use of arginine vasopressin analogue patients with nocturnal enuresis and nocturnal polyuria become dry

41. 排尿障礙治療中心 版權所有 Etiologies of Nocturia Detrusor instability Hypersensitive bladder Bladder outlet obstruction Nocturnal polyuria Small bladder capacity

42. 排尿障礙治療中心 版權所有 Impact of Nocturia on the Elderly Elderly patients are likely to be exposed to serious health risks Nocturia causes fatigue due to sleep deprivation Increase chance of traumatic injury through falling from 10 to 21% with >2 voids per night

43. 排尿障礙治療中心 版權所有 Side Effects of Desmopressin Hyponatremia Water retention Side effects can be eliminated after discontinuing medication Federal law cautions against its use in patients over 65 years

44. 排尿障礙治療中心 版權所有 Effects of Urodynamics on Therapeutic Effects of Desmopressin Patients with small bladder capacity and detrusor instability might not benefit from desmopressin if no nocturnal polyuria Children with NE have been noted to be cured after DDAVP therapy Can the bladder learn to hold more urine and reduce nocturnal voiding frequency

45. 排尿障礙治療中心 版權所有 Materials and Methods Patients with severe nocturia refractory to previous treatment All patients had > 3/N nocturia and nocturnal urine volume > 35% daily voided volume Urodynamic pressure flow study, patients with BOO or residual urine >100mL were excluded

46. 排尿障礙治療中心 版權所有 Desmopressin Treatment A one week entry test A 3-day voiding diary was recorded and nocturnal urine amount was calculated A nocturnal urine sample taken for U/A and specific gravity test Serum BUN, Cr, Na, K were measured Patients with both nocturnal frequency and polyuria were enrolled

47. 排尿障礙治療中心 版權所有 Therapeutic Effects of Desmopressin in NocturnalPolyuria BaselinePosttreatment P Value (Paired t Test) Nocturnal frequency (time/night) 5.20 ± 1.162.24 ± 1.12<0.0001 Nocturnal urine volume (mL) 955.6 ± 255.9255.8 ± 210.5<0.0001 Quality of life 4.47 ± 1.071.05 ± 0.91<0.0001 Urine specific gravity 1.012 ± 0.0071.016 ± 0.0050.011 Serum Sodiun (mEq/L) 139.5 ± 4.34139.7 ± 3.840.761 Serum Potassium (mEq/L) 4.46 ± 0.354.31 ± 0.440.022

48. 排尿障礙治療中心 版權所有 Effects of Bladder Capacity after Desmopressin Therapy Baseline cystometric capacity (mL) Pretreatment nocturnal bladder capacity (mL) Post-treatment nocturnal bladder capacity (mL) P Value* Good effect (n=20) 235.0 ± 102.5185.6 ± 39.3260.2 ± 106.90.006 Failed (n=8) 262.9 ± 108.9162.7 ± 88.0200.0 ± 134.30.216 P value 0.5010.3530.226 Nocturnal bladder capacity = mean nocturnal urine amount/ mean nocturnal frequency. *Comparing prectreatment and post-treatment findings.

49. 排尿障礙治療中心 版權所有 Changes of Nocturnal Frequency after Desmopressin Therapy Baseline urodynamic Results Return to Baseline Improved over Baseline Same as Post- treatment P Value With DI (15)276>0.1 Without DI (10)460 BC ≦ 250mL (17) 1106<0.05 BC > 250mL530 Total (25)6 (24%)13 (52%)6 (24%) KEY: DI = detrusor instability; BC= bladder capacity.

50. 排尿障礙治療中心 版權所有 Common Causes of Low Nocturnal Bladder Capacity Infravesical obstruction Idiopathic nocturnal DI Neurogenic bladder dysfunction Cystitis (Bacterial, interstitial, TB, radiation) Cancer of bladder, prostate, urethra Learned voiding dysfunction Anxiety disorders Pharmacological: xanthines (theophylline, caffeine), beta-blockers Bladder or lower ureteral calculi

51. 排尿障礙治療中心 版權所有 Combnation therapy for geriatric Nocturnal polyuria and Nocturia Combined anticholinergics and DDAVP for detrusor overactivity and nocturnal polyuria for DI & NP Combined alpha-blocker and DDAVP for BOO and NP Combined alpha-blocker and anti- cholinergics and DDAVP for BOO & DI & NP