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UrodynamicUrodynamic Study (UDS) in Study (UDS) in UrogynecologyUrogynecology

吳銘斌吳銘斌1,2 1,2 (Ming(Ming--Ping Wu)Ping Wu)

奇美醫院奇美醫院婦產部婦產部婦女泌尿科婦女泌尿科1 1

台北醫學大學醫學院台北醫學大學醫學院婦產學科副教授婦產學科副教授22

Bladder & Urethra function Bladder & Urethra function during storage and voidingduring storage and voiding

Normal Normal StorageStorage VoidingVoidingBladderBladder RelaxedRelaxed ConstrictedConstricted

UrethraUrethra ConstrictedConstricted RelaxedRelaxed

Abnormal Abnormal StorageStorage VoidingVoidingBladderBladder OveractiveOveractive UnderactiveUnderactive

AcontractileAcontractile

UrethraUrethra Incompetent under Incompetent under stressstress

Functional or Functional or anatomic obstructionanatomic obstruction

Inappropriate Inappropriate relaxationrelaxation

URODYNAMIC (UDS) ICS Abbreviations

URODYNAMIC (UDS) URODYNAMIC (UDS) ICS AbbreviationsICS Abbreviations

Pura

Pdet

Pabd

QuraEMG

Pves

Pves Vesical Pressure Pabd Abdominal PressurePdet Detrusor PressurePura Urethral PressureQura Urinary Flow rateEMG Electromyography

Stanton SL,Tanagho EA 1986 Springer-Verlag

Normal Normal micturitionmicturition cyclecycle

Stanton S L,Tanagho E A 1986 Springer-Verlag

Mechanism of urinary incontinenceMechanism of urinary incontinence

a: normal voiding or DO; b: DSD; c: impair bladder compliance; d: urethral instability; e: USI

ICS TerminologyICS Terminology

Chapple CR 2005 Nat Clin Practice UrolAbrams P 2002 Neurourol Urodyn

Urodynamics (UDS)

Life Tech Co.

Look inside the UDS machineLook inside the UDS machine

Keyboard

Monitor /Display

Computer (PC)

Printer

Mouse

Patient unit Cable

Puller /Profilometer

Patient Unit

UroPump

Infusion Medium

EMG

Remote Control

Life Tech Co.

Pressure Transducers and Tubing

UDS- components

Life Tech Co.

Select InvestigationUrodynamic investigations

Electromyography (EMG)Electromyography (EMG)

(UPP)

(UFM)(CMG)

(PFS)

Recording Flow

Flow Transducer

Vura

Qura

Urodynamic Equipment

Uroflometry (UFR)UroflometryUroflometry (UFR)(UFR)

UROFLOWMETRY ParametersUROFLOWMETRY ParametersUROFLOWMETRY Parameters

Time s

Quraml/s

Vuraml

100(Qmax) Maximum Flow Rate

Flow TimeVoiding Time

(TQmax) Time to Max. Flow

Voided Volume

Voided Volume

(Qave) Average Flow RateVoided Volume / Flow Time

Time to 100 ml

(Peak Flow)

UroflowmetryUroflowmetry (UFM)(UFM)at least 200 ml needs to be voided to at least 200 ml needs to be voided to calculate reliable values. calculate reliable values. parameters are obtained: parameters are obtained: 1) flow rate (Q), ml/ sec1) flow rate (Q), ml/ sec2) maximum flow rate (2) maximum flow rate (QmaxQmax); );

> 15 ml/ sec > 15 ml/ sec

3) total flow time (3) total flow time (QtimeQtime); ); 4) average flow rate (4) average flow rate (QavgQavg); ); 5) total volume voided; 5) total volume voided; 6) 6) postvoidpostvoid residual urine volume (PVR)residual urine volume (PVR)

Cutoff: 50Cutoff: 50--100ml100ml< 20% total voids < 20% total voids

Kohli N 1998 Clin Obstet Gynecol

Abnormal Abnormal UroflowmetryUroflowmetry

(A) Superflow pattern with poor urethral resistance; (B) intermittent multiple peak pattern;e.g. DSD, abd. straining

(C) intermittent interrupted pattern; (D) obstructive pattern with increased outlet resistance or poor propulsive force

Single channel Single channel cystomterycystomtery (CMG)(CMG)


Normal Normal cystometrycystometry (CMG)(CMG)


(A)(A) Normal filling Normal filling cystometrycystometry; ;

Kohli N 1998 Clin Obstet Gynecol(B) phasic contractions (detrusor instability);

(C) phasic contractions with gradual rise in Pdet

Kohli N 1998 Clin Obstet Gynecol(D) (D) steady rise in rise in PdetPdet(low compliance bladder)(low compliance bladder)

Multichannel Multichannel cystometrycystometry (CMG)(CMG)


APIS

3-way

Pves

IPTS-DC-LT1

DLUPP-7D Dual Lumen CMG/UPP Catheter

Pdet = Pves – Pabd

Pves

UPDC

UPT

IV

CMG (Filling Pressure Flow Study)

APIS

RPC-9 Abdominal Pressure Catheter

Pabd

Pabd

Pdet = Pves – Pabd

CMG (Filling Pressure flow)

Indications for multichannel Indications for multichannel subtracted subtracted cystometrycystometry


TABLE


Pabd

Pves

Pura

Pdet

Pucp

Flow rate

Storagephase

H:9

H:3

EMG

1512F Wire ElectrodesH0959A Surface Electrodes

Electromyography (EMG)Electromyography (EMG)

EMG recordingEMG recording

Activity of the pelvic floor• External spincter• Detect Detrusor sphicter dys-synergia (DSD)

Filling of the bladder VoidingFilling of the bladder Voiding

CMG Basic PressureCMG Basic PressureCMG Basic Pressure

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf0 100 200 300 400 500 600 ml

20 m

l

Time 1 min/Div

CMG First Desire (FD)CMGCMG First Desire (FD)First Desire (FD)

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf0 100 200 300 400 500 600 ml

20 m

l

Time 1 min/Div

Speaking

FD

CMG Cough (C)CMG Cough (C)CMG Cough (C)

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf0 100 200 300 400 500 600 ml

20 m

l

Time 1 min/Div

Speaking

FDCough

CMG Normal Desire (ND)CMG CMG Normal Desire (ND)Normal Desire (ND)

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf0 100 200 300 400 500 600 ml

20 m

l

Time 1 min/Div

Speaking

FDCough

ND

Uninhibited Detrusor Contraction (UIDC)Uninhibited Uninhibited DetrusorDetrusor Contraction (UIDC)Contraction (UIDC)

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf0 100 200 300 400 500 600 ml

20 m

l

Time 1 min/Div

Speaking

FD

Cough

ND

> 15 cmH2O

UIDC

CMG Rectal Hyperactivity (RH)CMG Rectal Hyperactivity (RH)CMG Rectal Hyperactivity (RH)

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf0 100 200 300 400 500 600 ml

20 m

l

Time 1 min/Div

Speaking

FDCough

ND

UIDC

RHCough

Slow WavesAmplitude > 10 cmH2O

CMG Unstable Urethra (UU)CMG Unstable Urethra (UU)CMG Unstable Urethra (UU)

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf0 100 200 300 400 500 600 ml

20 m

l

Time 1 min/Div

Speaking

FD

Cough

ND

UIDC

RHCough

> 30 cmH2O

UU

CMG Strong Desire (SD)CMG Strong Desire (SD)CMG Strong Desire (SD)

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf0 100 200 300 400 500 600 ml

20 m

l

Time 1 min/Div

Speaking

FDCough

ND

UIDC

RHCough

UU

SD

Voiding:Voluntary Contraction

Autonomic Control

CMG Leak Point (LP)CMG Leak Point (LP)CMG Leak Point (LP)

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf0 100 200 300 400 500 600 ml

20 m

l

Time 1 min/Div

Speaking

FDCough

ND

UIDC

RHCough

UU

SD

Cough

Leak

Urgency & Maximum CapacityUrgency & Maximum CapacityUrgency & Maximum Capacity

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf0 100 200 300 400 500 600 ml

20 m

l

Time 1 min/Div

Speaking

FD

Cough

ND

UIDC

RHCough

UU

SD

Cough

Leak

UR

MC

CMG ComplianceCMG ComplianceCMG Compliance

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf0 100 200 300 400 500 600 ml

20 m

l

Time 1 min/Div

Speaking

FD

Cough

ND

UIDC

RHCough

UU

SD

Cough

Leak

UR

MC

P1

P2

Compliance =V2 - V1P2 - P1

V1V2

Two most common incontinenceTwo most common incontinenceUrodynamic stress incontinence (USI)

Detrusor overactivity (DOI)

UrodynamicUrodynamic stress incontinence (USI) stress incontinence (USI) DetrusorDetrusor overactivityoveractivity (DO) (DO)

UrodynamicUrodynamic stress incontinencestress incontinence

Nygaard & Heit2004 Obstet Gynecol

DetrusorDetrusor overactivityoveractivity incontinenceincontinence

Nygaard & Heit 2004 Obstet Gynecol

PressurePressure--flow studyflow study

Storage phaseStorage phaseVoiding phaseVoiding phase


Filling phase Voiding phase

PressurePressure--Flow StudyFlow Study


Pabd

Pves

Pura

Pdet

Pucp

Flow rate

Voiding phase

Voiding Mechanisms in Voiding Mechanisms in Neurologically Intact Women Neurologically Intact Women

Depending on Depending on •• age, menopausal status, age, menopausal status, •• total voided volume, total voided volume, •• the presence of lower urinary tract dysfunction, the presence of lower urinary tract dysfunction,

the patient may void the patient may void •• detrusordetrusor contraction, contraction, •• abdominal straining, abdominal straining, •• urethral relaxation, urethral relaxation, •• combination of three combination of three


Voiding Mechanisms in Voiding Mechanisms in Neurologically Intact Women Neurologically Intact Women


Pressure flow studyPressure flow study

1. low 1. low PdetPdet, high , high QmaxQmax•• unobstrucedunobstruced

2. high 2. high PdetPdet, low , low QmaxQmax•• obstrucedobstruced

3. low 3. low PdetPdet, low , low QmaxQmax•• Poor Poor detrusordetrusor contractilitycontractility

PdetPdet > 15 cm H> 15 cm H22OO•• Shorter postShorter post--op bladder drainageop bladder drainage

Definition for female bladder outlet Definition for female bladder outlet obstruction (BOO)obstruction (BOO)

GroutzGroutz A. A. BlaivasBlaivas JG, et al. 2000 JG, et al. 2000 NeurourolNeurourolUrodynUrodynMaximum flow rate (Maximum flow rate (QmaxQmax) < 12ml/s ) < 12ml/s DetrusorDetrusor pressure at peak flow pressure at peak flow ((PdetPdet at at QmaxQmax)> 20 cmH)> 20 cmH22O. O.

Massey JA & Abrams PH 1988 BJU Massey JA & Abrams PH 1988 BJU Maximum flow rate (Maximum flow rate (QmaxQmax) < 12 ml/s ) < 12 ml/s Maximum Maximum detrusordetrusor pressure (pressure (PdetPdet, max) > 50 , max) > 50 cmHcmH22O. O. PVR> 100mLPVR> 100mL

APIS

3-way

UPDC

UPT

IV

Pves

Urethral pressure profile (UPP)Urethral pressure profile (UPP)

IPTS-DC-LT1

DLUPP-7D Dual Lumen CMG/UPP Catheter

Pclo = Pura – Pves

PuraPves Pura


Max urethral pressure (MUP)Max urethral pressure (MUP)Max urethral closure pressure (MUCP)Max urethral closure pressure (MUCP)•• 64 y/oy/oMean 65 cmHMean 65 cmH22OO

•• Cutoff: 20 cmHCutoff: 20 cmH22O for ISDO for ISD

Functional urethral length (FUL)Functional urethral length (FUL)•• 2.42.4-- 2.8 cm (< 50 2.8 cm (< 50 y/oy/o))

UPPUPP


Resting UPPResting UPP

Life Tech Co.

Stress UPPStress UPP

Life Tech Co.

Resting UPP Stress UPP


Rectum Bladder

30°

Bladder filled with 200 ml, I'm Straining

with Increased Force up to Leak !

RecordingPabd & Pves

and Leaks withLeak Detectorand Flowmeter

Pabd

Pves

Qura

60 80 100 120

Leak

Vasalva Leak Point Pressure (VLPP)

VasalvaVasalva Leak Point Pressure Leak Point Pressure (VLPP)(VLPP)

VLPP and CLPPVLPP and CLPPPosition patient in almost upright Position patient in almost upright position for position for visual detectionvisual detection of of leakage. Use the remote control leakage. Use the remote control to mark the leakage.to mark the leakage.

VLPP and CLPPVLPP and CLPPAutomatic detectionAutomatic detectionLeakage detection via Leakage detection via conductance ringsconductance rings on a water on a water cathetercatheter

Leak point pressure (LPP)Leak point pressure (LPP)

Kohli N 1998 Clin Obstet GynecolVLPP: ValsalvaCLPP: Cough

Leak point pressure (LPP)Leak point pressure (LPP)

McGuire EJ 1993 J McGuire EJ 1993 J UrolUrolVLPP < 60cmHVLPP < 60cmH22OO•• Type III incontinenceType III incontinence•• Intrinsic sphincter deficiency (ISD)Intrinsic sphincter deficiency (ISD)

VLPP > 90cmHVLPP > 90cmH22OO•• Type I, II incontinenceType I, II incontinence•• Urethral Urethral hypermobilityhypermobility

Kohli N 1998 Clin Obstet GynecolVLPP: ValsalvaCLPP: Cough

Pressure transmission ratio Pressure transmission ratio (PTR) & Hammock theory (PTR) & Hammock theory

DeLancey JOL 19994 Am J Obstet Gynecol:

Abdominal pressure on urethra & pelvic floor

Pressure Pressure transmission ratio transmission ratio

(PTR)(PTR)

100%100%•• Equal pressure Equal pressure

transmission to transmission to urethra & bladderurethra & bladder


UrodynamicUrodynamic investigationsinvestigations Filling Pressure &

EMG recordig

Voiding Puller

Uroflow X

Cystometry X X

Pressure flow X X X

UPP X X

Gynaecology X X X X

Procedure of UDS in Procedure of UDS in UrogynUrogyn ClinicClinic1. 500ml water 1 hour before test1. 500ml water 1 hour before test2. Do Pad test2. Do Pad test3. Do 3. Do UroflowmetryUroflowmetry4. Insert infusion & pressure transducer 4. Insert infusion & pressure transducer

•• Check Check postvoidpostvoid residual (PVR)residual (PVR)5. Infusion 80ml/min5. Infusion 80ml/min6. CMG6. CMG

•• FS, cough (c)FS, cough (c)＊＊1, c1, c＊＊1, c1, c＊＊6, running water6, running water•• Max Capacity, cMax Capacity, c＊＊1, c1, c＊＊1, c1, c＊＊6, 6, •• Standing, cStanding, c＊＊1, c1, c＊＊1, c1, c＊＊6, 6,

7. VLPP 7. VLPP 8. Voiding pressure flow study8. Voiding pressure flow study9. UPP 9. UPP

•• Static UPPStatic UPP•• stress UPP stress UPP

Interpretation of UDS in Interpretation of UDS in UrogynUrogyn ClinicClinicAbnormal storageAbnormal storage•• DetrusorDetrusor overactivityoveractivity (DO)(DO)•• Low complianceLow compliance•• Low capacityLow capacity•• Hypersensitivity bladderHypersensitivity bladder

•• DetectionDetection•• Low MUCPLow MUCP•• Short FULShort FUL•• Low Low PcloPclo•• Low PTRLow PTR

Abnormal voidingAbnormal voiding•• Low flowLow flow•• Abdominal strainingAbdominal straining•• Abnormal PVRAbnormal PVR

UrodynamicUrodynamic stress incontinence (USI)stress incontinence (USI)

•Visual or conductance ring

Interpretation of UDS in Interpretation of UDS in UrogynUrogyn ClinicClinic

Description• UFR• CMG + EMG• Pressure flow study• UPP

Impression• Urodynamic stress incontinence (USI)• Detrusor overactivity (DO)• with/ without incontinence• Mixed type (USI + DO)• Detrusor sphincter dyssynergia

影像尿動力學診斷系統影像尿動力學診斷系統

Where

? Who?

How?

Apr 2004Apr 2004 6868

VideoVideo--urodynamicurodynamic studystudy

尿動力學檢查尿動力學檢查SolarSolar功能說明功能說明

n 中文Windows作業系統

n 紅外線遙控操作

n 週邊Plug & Play功能

n 可擴充藍芽(Blue- Tooth)功能

n 具自我診斷及校正軟體

n 任一PC可作判讀工作站

n 可擴充24H動態檢查儀

遠端遙控功能遠端遙控功能

透過醫院網路直接遙控尿動力檢查儀

Hospital Network

院內網路

辦公室

病房

尿路動力檢查儀

☆瀏覽患者檢查資料

☆直接遙控操作機器

☆Monitor監視

Apr Apr 2004200471

71

檢測軟體檢測軟體

Apr 2004Apr 2004 7272

影像尿動力學系統影像尿動力學系統Ｘ光機影像擷取Ｘ光機影像擷取

Apr 2004Apr 2004 7373

影像尿動力學系統影像尿動力學系統Ｘ光機單張影像擷取Ｘ光機單張影像擷取

Apr 2004Apr 2004 7474

影像尿動力學系統影像尿動力學系統

動態影像擷取動態影像擷取

Urodynamic Study (UDS)UrodynamicUrodynamic Study (UDS)Study (UDS)

• A. 21004C尿流速圖 (Uroflowmetry, UFR) …….…..….……• B. 21005C尿道壓力測量檢查

(Urethral pressure profile studies, UPP) .…………....1,254點21012B應力尿道壓力測量檢查

(Stress urethral pressure profile, Stress UPP) …….….• C. 21007C膀胱壓檢查(Cystometry, CMG) … ……………….

21011C壓力尿流速圖(Pressure-flow study) …….………• D. 21003C外括約肌肌電圖

(External sphincter electromyogram, EMG)

• E. 21006B錄影尿流動力學檢查( Video-urodynamic study)

VIDEO SPLIT

Thank you for your attention

2006. 02 Tainan

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