Urodynamic studyUrodynamic studyUrodynamic studyUrodynamic study

新光吳火獅紀念醫院 婦產科 新光吳火獅紀念醫院 婦產科 潘恆新醫師潘恆新醫師

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.

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

Urinary incontinence

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

Urinary incontinence

• Differential diagnosis– Genuine stress incontinence– Detrusor instability– Mixed incontinence– Overflow incontinence– Others

• Treatment: behavior training, medical or surgical treatment, electric stimulation…

Urodynamic study (UDS)• 1954 Davis• Provide objective evidence about lower urinary tra

ct 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

Frequency/volumecharting

• 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

Urodynamic study

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

Urodynamic study

• Uroflowmetry (UFM)• Cystometry (CMG): filling & voiding• Electromyography (EMG)• Urethral pressure profile (UPP):

– Static UPP– Stress UPP(sUPP)

Uroflowmetry (UFM)

Uroflowmetry (UFM)

• Indications:– As a screening test for voiding

difficulties – Measurement of residual urine

volume– Pre-operation evaluation for GSI

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)

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, positi

on, mechanism of filling, type of fluid used, sex, age, urine volume

Uroflowmetry (UFM)

Uroflowmetry (UFM)

Uroflowmetry (UFM)

Cystometry (CMG)• Detect bladder sensory, capacity, complian

ce, detrusor m. contraction• Factor affecting data:

– Patient position : upright better than supine– Filling medium: body temperature(37c) water o

r normal saline better than air– Filling rate:

• Slow-fill: < 10cc/min• Medium-fill: 10~100cc/min• Fast-fill : >100cc/min

Cystometry (CMG)

Cystometry (CMG)• Bladder sensation:

– FS: first sensation: 150cc

– FD: first desire to void: 250cc

– SD: strong desire to void: 400cc

– UG: urgency :> 400cc

– Voiding

Cystometry (CMG)• Bladder sensation: normal; absent;

decreased or increased

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)

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 run

ning water– No leakage on coughing– A Max. voiding detrusor pressure of less 50cmH

2O & Max. flow rate >15cc/s for a volume >150cc

Cystometry (CMG)

• Pitfalls:– Remove bubble – All connections should be tight– If possible , patient should have an empty rectu

m– Quality control

• Setting zero at atmospheric pressure• Calibrating the transducers• Fixed reference level for catheter: superior border of s

ymphysis pubis

Electromyography (EMG)

Purposes: 1. Identify the behavior of activity of a partic

ular muscle2. Demonstrate whether a muscle is normal,

myopathic or denervated/reinnervated3. Combine with cystometry: detect DSD( de

trusor sphincter dyssynergia )

Electromyography (EMG)

• Needle EMG : direct detect one muscle

• Surface-type EMG:

Urethral pressure profile (UPP)

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

Urethral pressure profile

-abnormal MUP

Urethral pressure profile-Pressure Transmission Ratio

Urethral pressure profile

• PTR: pressure transmission ratio(80~150%) GSI:<80%)

Urethral pressure profile-Pclo

Urethral pressure profile -rest

Urethral pressure profile-stress(sUPP)

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% )

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.

Genuine Stress Incontinence (GSI)

Bladder displacement TYPE III : intrinsic factor defect

UDS-disadvantage• Amount of urine leakage :---Pad test• GSI, subtype: type I, II, III (Blaivas,198

8)– Type I, II : bladder neck hypermobility– Type III : intrinsic factor defect

• 20% of GSI• Pclo <= 20 cmH2O• Stress leak point pressure : < 60cmH2O ( Pve

s )

Thank you !!