排排排排排排排排 排排排排 Lower Urinary Tract Symptoms in Women Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital
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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