排尿障礙治療中心版權所有 the role of urodynamics in stress urinary incontinence...

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The Role of Urodynamics in Stress Urinary Incontinence

Hann-Chorng Kuo

Department of Urology

Buddhist Tzu Chi General Hospital


Urodynamics Investigation of bladder and urethral

function in filling and voiding phases Confirmation of clinical diagnosis Provide evidence for selection of

therapeutic modalities Follow-up patients with unexpected

therapeutic results


Urodynamics and Stress Urinary Incontinence Detection of detrusor overactivity in patien

ts with SUI Differentiate types of SUI Analysis of underlying pathophysiology of

SUI Selection of surgical procedure for SUI Postoperative follow-up in patients with L

UTS and de novo urge


Role of Uroflowmetry and Postvoid residual urine in SUI A high Qmax with little PVR usually indicate nor

mal detrusor contractility A low Qmax with straining pattern may imply po

or relaxing urethral sphincter or low detrusor contractility

Large residual urine indicates inadequate voiding efficiency

Flow pattern is important in bladder function


Isolated sphincter obstruction after radical hysterectomy


Large cystocele and bladder outlet obstruction


Role of Urethral pressure profile in SUI Academic interest High false negative stress test rate A positive test simply imply existence of

anatomical SUI A low MUCP may indicate the existence of

intrinsic sphincter deficiency (20 cm water by microtip method, 60 cm water by perfusion method)


Low pressure transmission ratio


Changes of maximal urethral closure pressure with age

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)


Role of Cystometry in SUI Bladder capacity Bladder compliance Detrusor overactivity Detrusor contractility


Spontaneous detrusor contractions


Provoked detrusor contractions


Detrusor overactivity in a woman with Stress incontinence


Diagnosis of Lower Urinary Tract Dysfunction in SUI Poor compliant bladder with SUI – after

radical hysterectomy Detrusor overactivity with SUI– Stroke,

Parkinson’s disease Detrusor underactivity with SUI – Diabetes

mellitus, peripheral neuropathy Contracted bladder with SUI


Poor compliant bladder and SUI


Poor bladder compliance with low urethral resistance


Detrusor instability and mild Intrinsic sphincter deficiency


Detrusor overactivity without Anatomical stress incontinence


Pressure flow study Important urodynamic test for SUI Abnormal P/F results include low pressure

low flow, high pressure low flow BOO, acontractile bladder,non-relaxing urethral sphincter

Residual urine volume Sphincter EMG coordination


Normal bladder compliance with low urethral resistance and SUI


Uterine prolapse and cystocele causing bladder outlet obstruction


Reduction of prolapse relieves BOO in patient with SUI


Leak Point Pressure measurement Detrusor LPP Abdominal LPP

Valsalva LPP

Cough LPP Difference in CLPP and VLPP Clinical significance in CLPP and VLPP


Measuring LPP and Pressure flow study in SUI


Leak point pressure in SUI Cough LPP and Valsalva LPP should be

measured concomitantly VLPP measures intrinsic urethral resistance CLPP measures resistance from intrinsic

and extrinsic continence mechanisms Measure the pressure at exactly the point

that urine loss


Cough v Valsalva Leak-point pressure


Pelvic Floor RelaxationLow LPP without Hypermobility


Pelvic Floor Relaxation High LPP with hypermobility


Pelvic Floor RelaxationCLPP>VLPP, mild hypermobility


Pelvic Floor RelaxationCLPP=VLPP with hypermobility


Relationship of MUCP and Leak-point pressures A low MUCP is significantly correlated

with a low LPP Patients with a low MUCP may raise

suspicion of intrinsic sphincter deficiency Patients with high grade cystocele may

have a high LPP but MUCP remains low in existence of ISD


Relationship of LPP, BN Descent and Grade of SUI

Grade 1 SUI(n= 47)

Grade 2 SUI(n= 41)

Grade 3 SUI(n= 28)

Statistics P value

CLPP (cm H2O) 135.8 ± 30.9 110.0 ± 26.7 90.6 ± 36.7 0.000

VLPP (cm H2O) 107.2 ± 32.9 65.8 ± 22.4 50.5 ± 31.1 0.000

BN descentat CLPP (cm)

1.149 ± 0.6500.976 ± 0.64

20.589 ± 0.562 0.001

BN descentat VLPP (cm)

1.383 ± 0.8021.098 ± 0.70

00.679 ± 0.670 0.001

Mean ± standard deviation, SUI=stress urinary incontinence, CLPP= cough leak point pressure, VLPP= Valsalva leak point pressure, BN= bladder neck


Relationship ofCLPP, VLPP and BN Descent

VLPP <60(n= 41)

60<VLPP<90(n= 36)

VLPP >90(n= 39)

Total

CLPP=VLPPBN < 1.0 cm

3 (7.3%) 1 (2.8%) 1 (2.6%) 5 (4.3%)

CLPP=VLPPBN > 1.0 cm

0 2 (5.6%) 8 (20.5%) 10 (8.6%)

CLPP>VLPPBN < 1.0 cm

22 (53.6%) 7 (19.4%) 6 (15.4%) 35 (30.2%)

CLPP>VLPPBN > 1.0 cm

16 (39%) 26 (72.2%) 24 (61.5%) 66 (56.9%)

Total 41 36 39 116


Hypermobility of Bladder neck & urethra


Correlation of MUCP with VLPP and CLPP


Urethral pressure profilometry in Diagnosis of SUI Perfusion UPP or microtip catheter UPP A lower MUCP was measured by microtip

catheter A lower MUCP is associated with a lower

Valsalva LPP (p=0.011) and cough LPP (p= 0.005)

Dynamic UPP to measure pelvic floor muscle contractility and effect on urethra


Videourodynamic study & SUI Thorough examination of bladder and

urethral anatomy & function Accurate measurement of leak-point

pressure Provide patient’s education


Bladder neck Incompetence in SUI Urethrovesical facilitative reflex may exist

in women with an incompetent bladder neck

Adequate bladder neck suspension to close the bladder neck and prevent persistent postoperative urge

A BN incompetence may associate higher grade SUI


Measurement of hypermobility of bladder neck


Endosonoraphy of Bladder and urethra in SUI


Measurement of Urethral striated muscle component


Poor urethral striated muscle component in type III SUI


Reduced striated muscle component in SUI

Patients NCross-Sectional Area

(mm2)

Smooth Muscle Component

(mm2)

Striated Muscle Component

(mm2)

A.Non-SUI 51 104.4 ±35.6 46.1±22.5 58.3±27.3

B.SUI 60 86.7 ±29.9 43.9±19.0 42.8±20.7

Cystocele* (9) 75.7 ±23.1 37.9±12.2 37.8±22.8

Statistics A vs B:P=0.005 NS A vs B: P=0.001


Videourodynamics in Evaluation of PFMT Determine abdominal leak point

pressure

Measure bladder base descent during

straining

Measure bladder base elevation during

PME

Educate patient to perform an effective

PME


Predictive Factors for a Successful Physiotherapy

Low patient age and presence of estrogen Absence of detrusor instability Absence of intrinsic sphincteric deficienc

y Low urethral hypermobility Good compliance with treatment


Good PTR and Pelvic floor contraction pressure


Low PTR and good pelvic floor contraction pressure


Equal pressure transmission in urethra during stress UPP


Higher pelvic floor muscle contraction pressure at distal urethra


The Urodynamic Parameters after Pelvic Floor Muscle Training (I)

Pre-treatmen

t

Post-treatment

Statistics (p value)

Qmax (mL/s) Total22.6 ± 13.

0 20.9 ± 10.2 0.390

Successful

26.0 ± 10.77 23.4 ± 10.7 0.236

Failure18.3 ± 14.

9 17.8 ± 9.2 0.881

Voided volume

Total340.5 ± 12

3.4 386.1 ± 152.9 0.240

Successful

395.4 ± 69.8 414.1 ± 176.3 0.780

Failure273.3 ± 14

4.5 351.9 ± 119.4 0.021

FSF (mL) Total101.0 ± 26.

8 128.2 ± 41.6 0.025

Successful

96.1 ± 21.1 136.4 ± 45.8 0.027

Failure107.0 ± 32.

7 118.1 ± 35.7 0.484

FS (mL) Total189.0 ± 47.

5 229.5 ± 46.9 0.006

Successful

190.4 ± 51.4 245.0 ± 47.4 0.015

Failure187.3 ± 45.

2 210.4 ± 40.9 0.218


The Urodynamic Parameters after Pelvic Floor Muscle Training (II)

Pre-treatment

Post-treatment


Cystometric Capacity (mL)

Total 288.2 ± 83.8 338.0 ± 96.1 0.050Successful

303.0 ± 82.9 377.8 ± 100.6 0.086

Failure 270.1 ± 86.0 289.3 ± 66.8 0.376Compliance (mL / cmH2

O)

Total 63.8 ± 69.7 138.3 ±170.3 0.069Successful

58.7 ± 53.0 190.4 ± 208.0 0.045

Failure 70.0 ± 89.1 74.7 ± 80.4 0.914Pdet (cmH2

O) Total 22.5 ± 9.0 21.9 ± 10.3 0.777

Successful

21.5 ± 8.9 18.3 ± 8.3 0.328

Failure 23.8 ± 9.5 26.2 ± 11.3 0.465LPP(cmH2O)

Total 111.7 ± 43.9 113.9 ± 20.7 0,816

Successful

122.3 ± 44.9 109.3 ± 23.3 0.518

Failure 99.6 ± 42.8 119.3 ± 17.4 0.233


The Urodynamic Parameters after Pelvic Floor Muscle Training (III)

Pre-treatment

Post-treatment


MUCP (cmH2O)


72.5 ± 24.3 76.9 ± 23.6 0.393

Failure 78.9 ± 37.5 62.7 ± 23.3 0.047FPL (mm) Total 34.5 ± 4.59 36.6 ± 4.9 0.300

Successful

34.4 ± 4.9 36.3 ± 5.1 0.089

Failure 34.8 ± 4.4 36.9 ± 5.0 0.198PTR (%) Total 47.9 ± 15.1 50.8 ± 10.2 0.486

Successful

51.6 ± 17.4 50.2 ± 9.9 0.847

Failure 43.4 ± 11.1 51.7 ± 11.1 0.049PFC (cmH2O) Total 15.7 ± 13.4 23.0 ± 22.2 0.043

Successful

20.5 ± 12.5 36.0 ± 21.2 0.009

Failure 9.9 ± 12.7 7.1 ± 9.6 0.051


The Urodynamic Parameter after Pelvic Floor Muscle Training ( )Ⅳ

Pre-treatment

Post-treatment


Resting BN position (cm)


1.14 ± 0.95 1.54 ± 1.21 0.213

Failure 1.72 ± 1.20 1.77 ± 1.06 0.886Straining BN position (cm)


2.55 ± 1.56 2.18 ± 1.53 0.372

Failure 3.13 ± 2.12 2.44 ± 1.45 0.270

BN descent

(cm)


1.31 ± 1.19 0.59 ± 0.37 0.031

Failure 1.61 ± 0.78 0.78 ± 0.62 0.004BN elevated PFMT (cm)


1.14 ± 0.32 1.91 ± 0.44 0.000

Failure 0.44 ± 0.39 0.78 ± 0.51 0.022


Cystometry biofeedback for urge incontinence For women who failed electrical stimulation, were

intolerant to anticholinergics, Urodynamic detrusor overactivity was proven Performed several voluntary PFMC at episodes of

DI while watching CMG tracing and EMG activity

Try to inhibit urge incontinence as longer duration as possible at home


Detrusor overactivity and CMG biofeedback


Biofeedback to inhibit detrusor instability


Postoperative follow-up of LUTS Frequency urgency – persistent bladder

neck incompetence Urge incontinence – bladder outlet

obstruction Difficult urination – bladder outlet

obstruction, bladder hypersensitivity Stress incontinence – inadequate urethral

resistance, existence of type III SUI


Urodynamic results after pubovaginal sling procedure

Mean (SD) variableA (before)

B (at 7 days)

C (at 3 months)

P<0.05

Qmax (mL/s) 13.0(7.3) 13.1(6.5) 17.5(5.7) A vs C,B vs

C

Capacity (mL)275(11

3) 253(61.32) 269(67.1) NS

Pdet (cmH2O) 20.3(10.5) 21.9(10.3) 21.3(7.1) NS

BN opening time (s) 8.5(8.1) 24.3(27.1) 12.1(10.3) A vs B

Residual vol. (mL)47.9(53.

7) 38.5(62.1) 15.7(23.9) NS


Videourodynamic results after Pubovaginal sling procedure


Selection of Treatment modality for SUI by Urodynamics Type I – behavioral therapy, pelvic floor m

uscle exercises Type II – pelvic floor exercises, anterior co

lporrhaphy, pubovaginal sling procedure Type II/III – pubovaginal sling procedure a

t proximal urethra Type III – pubovaginal sling at mid-urethra,

urethral collagen injection


Long term (5-year) results of Anti-incontinence surgery

n(a)Gittes BNS

(n=62)(b)Raz BNS

(n=53)(c)Pubovaginal sling(n=42)

Statistics

n % n % n %

Dry 60 25 40.3 12 22.6 23 54.8 (a)vs.(b)p<0.05

Improved 61 20 32.3 25 47.2 16 38.1 (b)vs.(c)p<0.05

Success rate 45 72.6 37 69.8 39 92.9 (a)vs.(c)p<0.05

Moderate SUI 21 11 17.7 8 17.0 2 4.8 (b)vs.(c)p<0.05

Severe SUI 15 6 9.7 8 15.1 1 2.3


Success rates of SUI in Different surgical procedures

n(a)Gittes BNS (n=62)

n(b)Raz BNS (n=53)

(c)Pubovaginal sling(n=42)

Statistics

n % n % n %

Type I SUI 12 8/10 80.0 2/2 100.0

Type II SUI111

32/41 78.0 33/47 70.2 23/23 100.0 nonsignificant

Type III SUI

34 5/11 45.5 2/4 50.0 16/19 84.2 (a)vs.(c)P<0.05

(b)vs.(c)P<0.05


Videourodynamics in Post-incontinence surgery & BOO


Iatrogenic urethral obstruction


Detrusor overactivity in a woman after anti-incontinence surgery


Transrectal sonography after PVS

IncompetentBladderNeck

Symphysispubis

Urethra

* *Sling

BA

BladderNeck

Urethra

Preoperative PostoperativeSymphysispubis

排尿障礙治療中心 版權所有 the role of urodynamics in stress urinary incontinence...

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排尿障礙治療中心版權所有 the role of urodynamics in stress urinary incontinence...