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.tw

1. 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

2. 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

4. 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

5. AUA Symptom Index

6. 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

7. Bladder Diary

8. 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

10. 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

11. 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

13. 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

15. 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

16. 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)

17. CMG

18. CMG Normal Normal

19. CMG Detrusor Hyperreflexia Poor Compliance DI

20. CMG BOO with DI DHIC

21. CMG Detrusor Arflexia Detrusor Underactivity

22. CMG Bladder Hypersesitivity

23. 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

24. UFM(voided volume)

25. UFM(Qmax)

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

27. UFM(flow pattern) Compressive-outlet Compressive-Detrusor

28. UFM(flow pattern) Intermittent

29. 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

30. EMG Normal Normal

31. EMG Artifact

32. EMG Pseudodyssynergia with DI

33. EMG Pseudodyssynergia Spinning top

34. EMG Poor relaxation

35. EMG DESD type1 DESD type2

36. EMG B-C reflex DESD type3

37. 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

38. Stress UPP SUI

39. UPP for pelvic floor exercise(1) Effective

40. UPP for pelvic floor exercise(2) Ineffective

41. 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

42. PFS Pdet.Qmax-2Qmax=AG number

43. PFS Pitfall 1

44. PFS Pitfall 2

45. PFS Pitfall 3 Pitf

46. PFS Upper tract obstruction? >22 cmH2O <15 cmH2O

47. PFS Obstruction

48. PFS Non-obstruction

49. PFS Non-obstruction Non-reflux

50. PFS Pitfall!