Voiding Dysfunction 排尿障礙 翁偉哲 泌尿科高雄市立聯合醫院 20161209 醫師公會
下泌尿道的功能 儲存 STORAGE of adequate volumes of urine at low pressure & with no leakage
排空 EMPTYING that is Voluntary Efficient Complete Low pressure
Lower Urinary Tract is a Functionally Integrated Unit Ureteral Vesicle Junction Bladder Sphincter Urethra Neurologic control mechanisms
Anatomy & Neurophysiology of the Lower Urinary Tract Bladder (detrusor) Stores urine at low pressure Compresses urine for voiding
Urethra Conveys urine from bladder to outside world
Sphincter(s) internal & external Controls urine flow & maintain continence between voidings
Nervous system control of Lower Tract CNS
Spinal Sympathetics T10-L1 via hypogastric Nerve S2-S4 Parasympathetic via Pelvic N Somatic via Pudental N
Periaqueductal gray matter receives bladder filling info Frontal/parietal lobes & cingulate gyrus inibit lower micturation centers Hypothalamus center initiate voluntary voiding Pontine Micturation center excites Bladder & inhibits sphincter Cerebellum integrates
Autonomic NS receptor Distribution
Low pressure storage with continence CNS micturition centers
T1 0L1 S2S4
Outlet obstruction:
Sympathetic Îą-adrenergic stimulation of bladder neck & posterior urethra from T10-L1 via Hypogastric Nerve Somatic stimulation of External Sphincter from S2S4 via Pudental Nerve
Bladder Relaxation: Allows continent storage of significant volumes of urine at < 20 mmHg
β-adrenergic stimulation of bladder fundus from T10-L2 via Hypogastric Nerve decreases bladder tone
Voluntary Efficient Complete Low Pressure Voiding Outlet relaxation: CNS micturition Centers Inhibit sympathetic ι-adrenergic stimulation of bladder neck/posterior urethra & somatic stimulation of External T1 Sphincter 0Bladder Contraction: L1 S2CNS micturition Centers S4 Inhibits β-adrenergic bladder relaxation & stimulates Parasympathetic cholinergic stimulation of bladder fundus Allows complete emptying at pressures from S2-S4 via Pelvic Nerve < 40 mm Hg CNS micturition centers
Normal Voiding Study
Normal Voiding Study
Voiding dysfunction Voiding dysfunction usually presents in one of two ways. The first is in the form of symptoms. Symptoms related to voiding dysfunction are broadly referred to as lower urinary tract symptoms (LUTS).
Voiding dysfunction LUTS have classically been divided into obstructive symptoms such as difficulty initiating a stream, decreased force of urinary stream, need to push and strain to void (stranguria), hesitancy or intermittent urine flow, and irritative symptoms such as urinary frequency, urgency, and nocturia. In addition, symptoms of incontinence and lower abdominal or pelvic pain may exist.
Decompensation The second way in which voiding dysfunction presents is in the form of urinary tract decompensation such as incomplete bladder emptying or urinary retention, renal insufficiency, and recurrent urinary tract infections. It is possible for patients who present with urinary tract decompensation to have little or no symptoms.
Decompensation In the case of symptoms, evaluation and treatment are often driven by the degree of bother to the patient. In many cases, patients with mild LUTS of a minimal bother will not even bring these to the attention of their physician However, when urinary tract decompensation is diagnosed, a more aggressive diagnostic and treatment plan must be implemented.
Voiding dysfunction 1. Failure to store urine.
2. Failure to empty urine. 3. Failure to store and empty. 1. Bladder dysfunction (overactive, underactive). 2. Bladder outlet dysfunction (overactive, underactive). 3. Combined bladder and outlet dysfunction
Overactive Bladder OAB defined based on symptoms Urgency, with or without urge incontinence, usually with frequency and nocturia
In the absence of pathologic or metabolic conditions that might explain these symptoms 2002 ICS Terminology
OAB Symptoms Frequency
• 8 or more visits to the toilet per 24 hours • Urination at night 2 or more visits to toilet during sleeping hours
Urgency
Urge Incontinence
• Sudden, strong desire to urinate
• Sudden & involuntary loss of urine
OAB
URGENCY ć&#x20AC;Ľĺ°ż Urgent urination describes an overwhelming need to get to a restroom immediately. It may be accompanied by pain or discomfort in the bladder or urinary tract.
Frequent and urgent urination issues often occur together. You may feel the need to urinate often, and the urge comes on suddenly.
Anatomically, functional bladder capacity increases with age from childhood [(years of age + 2) Ă&#x2014; 30 ml] to adulthood (300â&#x20AC;&#x201C;400 ml).
尿流速檢查
Bladder Sensation .
First sensation of bladder filling The feeling when the people first becomes aware of bladder filling.
First desire to void The first feeling that the people may wish to pass urine.
Normal desire to void The feeling that leads the people to pass urine at the next convenient moment, but voiding can be delayed if necessary.
Strong desire to void The persistent desire to pass urine without the fear of leakage
A Hidden Condition Many patients self-manage by voiding 1.frequently, Many patients self-manage voiding reducing fluid by intake, and reducing fluid intake, and frequently, wearing pads wearing pads Nearly two-thirds of patients are 2.symptomatic Nearly two-thirds patients are seeking for 2ofyears before symptomatic for 2 years before seeking treatment treatment 30% of patients who seek treatment 3.receive 30% of patients who seek treatment no assessment noreceive assessment 4.Nearly Nearly80% 80%are are not not examined examined
Barriers to Treatment Patient misconceptions and fears
“Part of normal aging or everyday life” “Not or frequent enough to treat” “Partsevere of normal aging or everyday life” “Not severe or frequent enough to treat” “Too embarrassing to discuss” “Too embarrassing to discuss” “Treatment won't help” “Treatment won't help”
OAB Screening Can Help Diagnose Other Causes of Bladder Symptoms Local pathology infection bladder stones bladder tumors interstitial cystitis outlet obstruction
Metabolic factors diabetes polydipsia
Medications diuretics antidepressants antihypertensives hypnotics & sedatives narcotics & analgesics
Other factors pregnancy psychological issues
Differential Diagnosis: Physical Examination Perform general, abdominal (including bladder palpation), and neurologic exams Perform pelvic and/or rectal exam in females and rectal exam in males Observe for urine loss with vigorous cough
Differential Diagnosis: Laboratory Tests Urinalysis To rule out hematuria, pyuria, bacteriuria, glucosuria, proteinuria
Blood work if compromised renal function is suspected or if polyuria (in the absence of diuretics) is present
Suggested Reasons for Referral Symptoms do not respond to initial treatment within 2 to 3 months Hematuria without infection on urinalysis Recurrent symptomatic UTI Symptoms suggestive of poor bladder emptying Pelvic bladder, vaginal, or urethral pain
Evidence of complicated neurologic or metabolic disease Failed previous incontinence surgery Elevated PVR volume Radical pelvic surgery Symptomatic prolapse Prostate problems Surgery planned (2nd opinion)
Treatment Options Behavioral therapy Medication Combined therapy: behavioral and pharmacologic therapy Minimally invasive therapies Botulinum A-toxin Neuromodulation
Surgery
Pharmacotherapy Anticholinergic Agents Oxybutynin (Ditropan) Oxybutynin transdermal (Oxytrol) Tolterodine (Detrol) Solifenacin (Vesicare) Trospium chloride (Sanctura) Darifenacin (Enablex) Betmiga (Mirabegron)
Nocturia 夜尿 Definition: voiding during (nocturnal) sleep time Etiology (pathologic & non-pathologic causes): • Bladder - doesn’t hold enough • Volume - kidneys make too much urine • Sleep – insomnia
Evaluation: bladder diary
Nocturia Bother & Disordered Sleep High levels of bother are associated with:
difficulty falling asleep difficulty returning to sleep greater morning fatigue
Etiology of Nocturnal Polyuria Excessive nighttime fluid intake Diabetes mellitus Obstructive sleep apnea Peripheral edema Congestive heart failure Medications (SSRIâ&#x20AC;&#x2122;s, tetracycline)
Smoking
Etiology of Small Bladder Capacity Prostatic obstruction Idiopathic detrusor overactivity Neurogenic bladder Acquired voiding dysfunction Cancer of bladder, prostate, or urethra Pharmacologic agents Bladder calculi Ureteral calculi
Empiric Treatment Behavioral: – Reduce caffeine and alcohol – Limit night-time fluids – Improve sleep hygiene (attention to room temperature, noise, and lighting) Additional interventions: – Edema: leg elevation and compression stockings – LUTS: alpha blockers – OAB: anticholinergics … – Difficulty falling back asleep
Nocturia is common Increases with advancing age Bother and quality of life correlate with: Severity of nocturia Difficulty falling back asleep May impact general health Nocturia > 2 per night correlates with increased mortality
Urinary retention
Obstruction of the urethra Nerve problems Medications Weakened bladder muscles
Obstruction of the Urethra Urethral stricture, Urinary tract stones, Cystocele, Rectocele, Constipation, Certain tumors and cancers can cause an obstruction.
Nerve Problems Vaginal childbirth Brain or spinal cord infections or injuries Diabetes Stroke Multiple sclerosis Pelvic injury or trauma Heavy metal poisoning
Medications Antihistamines Anticholinergics/anti spasmodics Tricyclic antidepressants Decongestants Nifedipine Carbamazepine
Diazepam NSAID Amphetamines Opioid analgesics Over-the-counter cold and allergy medications
How common is urinary retention? In men 40 to 83 years old, the overall incidence of urinary retention is 4.5 to 6.8 per 1,000 men. For men in their 70s, the overall incidence increases to 100 per 1,000 men. For men in their 80s, the incidence of acute urinary retention is 300 per 1,000 men.
Bladder health The main functions of your bladder are to store and pass urine. Your bladder has to store enough urine, between 250 and 500mls, to allow you to undertake daily activities and have enough sleep. If you make your bladder hold too much urine, that is more than 600mls, this can damage your bladder.
Bladder health You need to empty your bladder completely and regularly every 3 to 4 hours during the day. It is not normal for you to strain to empty your bladder.
Some reasons why your bladder may not empty properly: Constipation Women who do not sit on the toilet properly Being in a rush and not allowing enough time to empty your bladder Inhibited when passing urine in public toilets Not having enough privacy to pass urine Not being in the correct position to pass urine
Passing urine often so your bladder never has enough pressure to have a good flow Your bladder muscle does not push out your urine effectively (detrusor failure) Enlargement of the prostate gland in men causing outflow obstruction Nerve damage to the bladder such as in Multiple Sclerosis Sometimes following gynaecological surgery for urinary leakage Certain medications such as oxybutynin Taking very strong painkillers causing you to lose bladder sensation
The effects of poor bladder emptying may include: No symptoms associated with poor bladder emptying Frequent visits to the toilet to pass urine (frequency) Getting up more at night to pass urine (nocturia) Feeling tired due to lack of sleep Dribbling after passing urine (post micturition dribble, PMD) Your urinary stream / flow is poor When passing urine you stop and start (intermittency)
Takes longer to pass urine Straining to pass urine Difficulty in starting the flow of urine (hesitancy) Always feeling uncomfortable because your bladder is never empty Urinary leakage during the day and night (incontinence) Need to use pads because of urinary leakage Increased risk of having urinary tract infections (UTI) and cystitis Your tummy is swollen - abdominal bloating Kidney problems and permanent damage in some cases Disruption to your daily activities and life style.
DM, 39 y/o male, PVR 260+ ml
URINARY INCONTINENCE UI is the involuntary loss of urine that is objectively demonstrable and a social or hygienic problem. 15-30% of community dwelling persons 65 years and older. F>M until age 80 years, then M=F
Risk Factors for UI Impaired mobility Depression Stroke Diabetes Parkinsonâ&#x20AC;&#x2122;s Disease Dementia (moderate to severe) 1/3 have multiple conditions FI, Obesity, CHF, Constipation,TIAs, COPD, Chronic cough, Impaired mobility
Consequences of UI Cellulitis, Pressure ulcers, UTI Falls with fractures Sleep deprivation Social withdrawal, depression Embarrassment (50%), interference with activities â&#x2020;&#x2018; Caregiver burden, contributes to institutionalization
Types of Urinary Incontinence Transient UI (Acute) Established UI (Chronic) Urge UI Stress UI Mixed UI Overflow UI “Functional” UI
Transient Incontinence Lower urinary tract pathology Precipitated by reversible factor 1/3 Community dwelling 1/2 Hospitalized incontinent aged patients Causes: Delirium, UTI, Meds, Psychiatric disorders, â&#x2020;&#x2018; UO, Stool impaction Restricted mobility
Pharmacologic Causes Opioids Calcium channel blockers Anti-Parkinsons drugs Anti-cholinergics Prostaglandin inhibitors
Depress detrusor activity & produce urinary retention and overflow incontinence
Pharmacologic Causes sedatives
↓ awareness, ↓detrusor activity →Func & O UI
loop diuretics Alcohol
Diuresis overwhelms bladder capacity →Urge & O UI Polyuria, ↓ awareness → Urge & Functional UI
caffeine
Polyuria, ↑ detrusor activity → Urge
cholinergics (donepezil)
↑ detrusor activity → Urge
Detailed History Duration, previous evaluation/treatment? Volume, how often, what situations? Urgency, dysuria, straining?
Post-Void Residual (PVR) Measure volume of urine left in bladder after voiding by catheter or bladder scan < 50 Normal 100â&#x20AC;&#x201D;400 Monitor until consistently less than 200cc. > 400ccâ&#x20AC;&#x201D;Insert Foley catheter
Management of UI Treat reversible cause (ie. Constipation) Review medications General measures: Behavioral interventions before pharmacologic Rx,. Avoid caffeine & ETOH, minimize evening intake, pads, Surgery last.
Pelvic Muscle exercises Motivated patient, careful instruction 56-95% decrease in UI episodesâ&#x20AC;&#x201D; dependent on intensity of program Focus on pelvic muscles (10 ctx 3-10 times/d)â&#x20AC;&#x201D;avoid buttock, abdomen, thigh muscle contraction. Biofeedback may help
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