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 M000732@ms.skh.org.tw

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

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

AUA Symptom Index

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

Bladder Diary

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

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

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

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

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

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)

CMG

CMG Normal Normal

CMG Detrusor Hyperreflexia Poor Compliance DI

CMG BOO with DI DHIC

CMG Detrusor Arflexia Detrusor Underactivity

CMG Bladder Hypersesitivity

Uroflowmetry(UFM) Simple, non-invasive, favorably repeatable Answer only one question: flow rate and trace itself Voided volume<100-150ml vs. corrected Qmax Low flow rate, outlet or detrusor impairment

UFM(voided volume)

UFM(Qmax)

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

UFM(flow pattern) Compressive-outlet Compressive-Detrusor

UFM(flow pattern) Intermittent

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

EMG Normal Normal

EMG Artifact

EMG Pseudodyssynergia with DI

EMG Pseudodyssynergia Spinning top

EMG Poor relaxation

EMG DESD type1 DESD type2

EMG B-C reflex DESD type3

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

Stress UPP SUI

UPP for pelvic floor exercise(1) Effective

UPP for pelvic floor exercise(2) Ineffective

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

PFS Pdet.Qmax-2Qmax=AG number

PFS Pitfall 1

PFS Pitfall 2

PFS Pitfall 3 Pitf

PFS Upper tract obstruction? >22 cmH2O <15 cmH2O

PFS Obstruction

PFS Non-obstruction

PFS Non-obstruction Non-reflux

PFS Pitfall!

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

LPP High DLPP with bil.hydronephrosis

LPP Valsalva or Cough Val Vals

LPP Interplay of ISD and Hypermobility

LPP Intrinsic vs extrinsic

LPP Type 3 SUI

LPP Type 2 SUI

LPP Type 1 SUI

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

VUDS BPH with BOO

VUDS Female SUI

VUDS SCI with DESD

VUDS Anterior Urethral Valve

VUDS Spinning Top Urethral Sphincter Spasm

VUDS Cervical SCI with AD

VUDS PFMT for SUI

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