1. Urodynamic study 新光吳火獅紀念醫院 婦產科 潘恆新醫師

2. Urinary incontinence Urinary incontinence is a condition in which involuntary loss of urine is a social or hygienic problem amd is objectively demonstrable U.I. is a symptom, not a diagnosis.

3. Urinary incontinence Prevalence: 15~30% of women of all ages Millions of individuals worldwide Etiology: Birth, dystocia, instrument delivery Menopause Occupation Habit Operation or radiotherapy

4. Urinary incontinence Diagnosis –History taking –Physical & pelvic examinations –Neurological examination –Urine analysis –Pad test –U.D.S.. Endoscopy. Radiology, Ultrasound. – Voiding diary –….

5. Urinary incontinence Differential diagnosis –Genuine stress incontinence –Detrusor instability –Mixed incontinence –Overflow incontinence –Others Treatment: behavior training, medical or surgical treatment, electric stimulation …

6. Urodynamic study (UDS) 1954 Davis Provide objective evidence about lower urinary tract function –Vesical pressure, abdominal pressure, detrusor pressure –Urethral pressure, urethral closure pressure –Uroflowmetry –EMG ( electromyography) Simple non-invasive to more complicated evaluations –Frequency/volume charting & uroflowmetry –video or ambulatory urodynamics

7. Frequency/volume charting Record 24-hour urinary output & fluid intake for several days –Total number of daily voids: 7~8 times –Average voided volume: 250cc –Functional bladder capacity: 400cc~600cc * Urgency, leakage, use of incontinence pad

8. Urodynamic study Indications: –Incontinence –Which type of incontinence? –? detrusor instability ( DI) –? Neurogenic bladder –Pre-& post- operation F/U

9. Urodynamic study Uroflowmetry (UFM) Cystometry (CMG): filling & voiding Electromyography (EMG) Urethral pressure profile (UPP): –Static UPP –Stress UPP(sUPP)

10. Uroflowmetry (UFM)

11. Indications: –As a screening test for voiding difficulties –Measurement of residual urine volume –Pre-operation evaluation for GSI

12. Uroflowmetry (UFM) Void Volume (V) Flow Time (FT) Peak Flow Rate(Qmax) Time to Peak Flow Rate (T Qmax) Average Flow (Qave) Residual Urine(PVR)

13. Uroflowmetry (UFM) Void Volume (V): >200cc Flow Time (FT): < 30 sec Peak Flow Rate (Qmax) : >15 cc/sec Time to Peak Flow Rate (T Qmax) Average Flow (Qave): >10cc/sec Residual Urine(PVR): <50cc~70cc * Factors affecting result: environment, position, mechanism of filling, type of fluid used, sex, age, urine volume

14. Uroflowmetry (UFM)

17. Cystometry (CMG) Detect bladder sensory, capacity, compliance, detrusor m. contraction Factor affecting data: –Patient position : upright better than supine –Filling medium: body temperature(37c) water or normal saline better than air –Filling rate: Slow-fill: < 10cc/min Medium-fill: 10~100cc/min Fast-fill : >100cc/min

18. Cystometry (CMG)

19. Bladder sensation: –FS: first sensation: 150cc –FD: first desire to void: 250cc –SD: strong desire to void: 400cc –UG: urgency :> 400cc –Voiding

20. Cystometry (CMG) Bladder sensation: normal; absent; decreased or increased

21. Cystometry (CMG) Pdet(detrusor)= Pves(bladder)-Prec(Abdomen) Detrusor activity –Normal (stable ) ; –Abnormal ( unstable, overactive) DI : defined as phasic contractions in which the pressure and then falls( pressure change of less than 5 cmH20 are ignored)

22. Cystometry (CMG) Normal value: –RU: <50cc –FDV: 150~200cc –Capacity :>400cc –Little or absent detrusor pressure rise on filling –No detrusor contraction during coughing or running water –No leakage on coughing –A Max. voiding detrusor pressure of less 50cmH2O & Max. flow rate >15cc/s for a volume >150cc

23. Cystometry (CMG) Pitfalls: –Remove bubble –All connections should be tight –If possible, patient should have an empty rectum –Quality control Setting zero at atmospheric pressure Calibrating the transducers Fixed reference level for catheter: superior border of symphysis pubis

24. Electromyography (EMG) Purposes: 1.Identify the behavior of activity of a particular muscle 2.Demonstrate whether a muscle is normal, myopathic or denervated/reinnervated 3.Combine with cystometry: detect DSD( detrusor sphincter dyssynergia )

25. Electromyography (EMG) Needle EMG : direct detect one muscle Surface-type EMG:

27. Urethral pressure profile (UPP)

28. Urethral pressure profile FUL: functional urethral length (2.5~4.5cm(3cm)) TUL: total urethral length(4cm) MUP: Maximal urethral pressure(65~135cm H2O(94)) Pclo=Pure-Pves

29. Urethral pressure profile -abnormal MUP

30. Urethral pressure profile - Pressure Transmission Ratio

31. Urethral pressure profile PTR: pressure transmission ratio(80~150%) GSI:<80%)

32. Urethral pressure profile -Pclo

33. Urethral pressure profile -rest

34. Urethral pressure profile -stress(sUPP)

35. UDS-Reading Abnormal storage function: –DI, –poor compliance bladder, –decreased capacity, –early bladder sensation Abnormal voiding function: –Low flow rate –Voiding by abdomen –Abnormal R.U. GSI: –Low MUP(< 80~90 cmH2O ) –Short functional urethral length( < 3cm) –Low Pclo ( <65 cmH20) –Low PTR ( <80% )

36. Genuine Stress Incontinence (GSI) ICS definition : involuntary loss of urine when the intravesical pressure exceeds the maximum urethral pressure (Pves > MUP) but in the absence of detrusor activity.

37. Genuine Stress Incontinence (GSI) Bladder displacementTYPE III : intrinsic factor defect

38. UDS-disadvantage Amount of urine leakage :---Pad test GSI, subtype: type I, II, III (Blaivas,1988) –Type I, II : bladder neck hypermobility –Type III : intrinsic factor defect 20% of GSI Pclo <= 20 cmH2O Stress leak point pressure : < 60cmH2O ( Pves )

39. Thank you !!