Transcript 슬라이드 1
Female Voiding Dysfunction:
What are We Trying to Treat?
Recent Advance in Management
권 동 득
Department of urology, Chonnam National University Hwasun Hospital
What’s the female voiding dysfuction?
Female voiding dysfunction is complex in nature poorly understood, lacks standard definition no consensus on diagnostic criteria difficult to treat
Majority of women – neurologically intact but cause is idiopathic
It’s common & affect QoL but paucity of literature on its management CHONNAM NATIONAL UNIVERSITY HOSPITAL
Female voiding dysfunction
No agreed classification specific to female voiding dysfunction ICS definition of voiding dysfunction
“A complex of symptoms represented by abnormalities of sensation related to voiding” Focusing on bladder and urethral activity during voding Bladder: detrusor underactivity, acontractile bladder Urethra: bladder outlet obstruction, intermittent involuntary contraction of periurethral muscle during voiding, detrusor sphinter dyssynergia, non-relaxing urethral sphincter obstruction
Abrams et al. Neurourol Urodyn 2002;21:119-167
CHONNAM NATIONAL UNIVERSITY HOSPITAL
Prevalence of LUTS and associated bother in women
Coyne KS et al. BJUI 2009;104:352-360
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Overlap of storage, voiding and postmicturition symptoms
EpiLUTS survey
15861 women
75% women reported at least one LUTS
Sexton CC et al. BJUI 2009;103:3:S12-S23
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Overlap of storage, voiding and postmicturition symptoms
Sexton CC et al. BJUI 2009;103:3:S12-S23
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Classification of voiding difficulties & retention
Monga AK. Textbook of urogynecology 2001, pp. 855-863.
Condition
Asymptomatic VD
Symptoms
Frequency UTI
Urodynamic data
Reduced flow, elevateated, normal or reduced voiding pressure with or without residual urine Symptomatic VD Acute retention Chronic retention Reduced stream, incomplete emptying, straining, frequency, UTI Peak flow <15ml/s, elevated voiding pressure with or without residual urine Painful or painless Reduced sensation, poor stream, incomplete emptying, straining, frequency, nocturia, incontinence, UTI Residual urine Flow<15ml/s Low or elevated voiding pressure, residual urine with or without upper tract dilatation
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Etiological factors
Idiopathic Most common cause, may be consequence of ageing
Urethral cause BOO intrinsic or extrinsic, Neurogenic bladder by detrusor sphincter dyssynergia, Intrinsic urethral stricture, urethral diverticulum, genital prolapse, Fowler’s syndrome, Hinman syndrome
Bladder cause Overdistension, hypocontractile or acontractile bladder, detrusor myopathy
Iatrogenic cause Anti-incontinence surgery (TVT, TOP), Pelvic surgery, Genital trauma, childbirth
Neurogenic cause DSD, non-relaxing urethral sphincter obstruction CHONNAM NATIONAL UNIVERSITY HOSPITAL
Etiological factors
Pharmacologic cause Anticholinergics and ganglion blocking agents, adrenergic agonist (duloxetine), anti-psychotics, anti-parkinsonian, antidepressants, opiate, some decongestants & antihistamine
Inflammatory cause Infective, allergic or chemical reaction of urogenital tissues, herpetic lesions
Endocrine cause DM, hypothyroidism
Psychological cause Depression, rape, schizophrenia CHONNAM NATIONAL UNIVERSITY HOSPITAL
Management of female voiding dysfunction
Often impossible to reverse or cure the underlying cause
The aim of treatment
Compensating and relieving symptoms
Minimizing long-term complication
Prevention is infinitively better than cure
Training medical staff & nursing staff to anticipate & rapid treat suspected urinary retention in patients at risk
- pelvic surgery, spinal anesthesia, childbirth - suboptimal voiding (SUI or extensive prolapse surgery) ; preop teach CIC & full informed consensus Protocols : UFM & RU CHONNAM NATIONAL UNIVERSITY HOSPITAL
Management of female voiding dysfunction
Risk factors for postoperative voiding dysfunction Age over 65 years Additional surgical procedure Type of surgical procedure Postop cystitis Preop acontactile bladder Excessive elevation of bladder neck Menopause Abnormal preop voiding studies Preop enterocele or vault prolapse CHONNAM NATIONAL UNIVERSITY HOSPITAL
Intermitternt self catheterization
Primary treatment for chronic retention
Improve quality of life & good long-term results
Less or no overflow incontinence
Reduce urinary tract infection
50% asymptomatic pyuria
Antibiotic prophylaxis for symptoms of cystitis
Unable or unwilling to self catheterization
Suprapubic rather than urethral catheter
Silicon or Teflon based catheter (change every 8wks)
Flip flow valve catheter, free drain at night only CHONNAM NATIONAL UNIVERSITY HOSPITAL
Pharmacotherapy
Often ineffective and high incidence of side-effects
Discontinuing causative medication
Tamsulosin ( α 1A / α 1D adrenergic antagonist)
improve Sx, Qmax, PVR
no RCT with small sample size
Diazepam
Relieving psychogenic & immediate postop VD (anxiety & pain)
Variable effectiveness CHONNAM NATIONAL UNIVERSITY HOSPITAL
Α blockers in female functional BOO
Tamsulosin 0.45mg for 1month in 18 women with functional BOO Diagnosed with urodynamic study (high Pdet, low Qmax, slient EMG)
Pischedda A et al. Urol Int 2005; 74:256-61.
Fig. 1. Q max values at baseline (dark column) and 30 days after tamsulosin treatment (open column) in the responder group.
Fig. 2. PVR at baseline (dark column) and 30 days after tamsulosin treatment (open column) in the responder group. Fig. 3. Maximum detrusor pressure at baseline (dark column) and 30 days after tamsulosin treatment (open column) in the responder group. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Pharmacotherapy
Medical treatment of voiding dysfunction Target organ
Stimulation of the bladder Relaxation of the urethral sphincter mechanism
Group of drug
Muscarinic agent Anticholinesterase α-adrenergic blokers Prostaglandins α-adrenergic blocking agents Mixed α1 and α2 adrenergic drugs α2 stimulants Muscle relaxants
Examples
Carbachol SC, Bethanechol Cl PO Distigmine bromide IM Tamsulosin, Propranolol PGE2, PGF2a intravesical Phenobenzamine, Prazosin Isoxsuprine hydrocholoride Terbutaline sulphate Dantrolene, Baclofen, Diazepam
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Pharmacotherapy
Oral contraceptives for ovarian supression
Topical nitric oxide
Anticholinergics combined with CIC
Botulinum toxin injection to relax urethral sphincter
Improvement after injection of botulinum toxin A injection (80-100U) (13women, neurogenic VD)
Effective reduction in urethral resistanc in detrusor overactivity with voiding dysfunction (50U) Sucessful in urinary retension after pubovaginal sling No evidence of effective in Fowler’s syndrome
Phelan M J of Urol 2005;165:1107-10 Kuo HC Urology 203;61:550-54 Smith CP et al Int Urogynecol J 2002;13:185-6
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Surgical treatment
Genital prolapse
Correction of prolapse
Urethral stricture
Hegar’s dilation or Otis urethrotomy
Trauma, scarring-> deterioration of VD or SUI
Bladder neck obstruction
Bladder neck incision and resection
VD after antiincontinence operation
No consensus on the management Loosening and cutting of the tape
Urethrolysis Idiopathic VD – urethrotomy or bladder neck incision ; no appropriate & advisable
Nguyen JK. Obs & Gyn Survey 202;57:468-75
CHONNAM NATIONAL UNIVERSITY HOSPITAL
Alternative therapies : Biofeedback & bladder retraining
Dysfunctional voiding
Learned maladaptive behavior
Effective bladder training
Primary bladder neck obstruction
Hinman syndrome
No side effects
Lido LM et al. Biofeedback self regul 1983;8:243-53.
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Neurostimulation
Electrical stimulation vaginal, anal, transdermal device
Sacral neuromodulation
No exact mechanism
Enable micturition reflex, modulate afferent signaling or central effect Improved voiding in non-obstructed retention, 20 patients, 15months f/u ; 18 out of 20 patients able to void after OP
(Shaker & Hassouna et al)
Bilateral stimulation, 33 patients, not superior to unilateral stimulation, - more effective in only partially response to temporary device
Shaker HS and Hassouna M. J of Urol 1998;159:1476-8.
Abosief S et al. BJU 2002;90:662-5.
Scheepens WA et al. J Urol 2002;168:2046-50.
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Posterior tibial nerve stimulation (PTNS)
Posterial tibial nerve contains L5-S3 fibers same level as parasympathetic innervation to bladder
Effective to treat female VD
Idiopathic non-obstuctive VD, (29 patients)
Needle stimulation above medial malleolus - 30 min, every 12 weeks - 50% reduction of catheter volume in 41% patients - After 12 sesseion, increase PdetQmax, reduction of RU, but same bladder capacity & none to free of CIC
Vandoninck V et al. Neurourol Urodyn 2004;23:246-51
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Conclusion
Prevention is better than cure
Etiology and management of voiding difficulty in women is different from those in men
Multidisciplinary approach for successful management
Limited role and evidence of neuromodulation, surgery, pharmacotherapy
Further study is needed in these areas CHONNAM NATIONAL UNIVERSITY HOSPITAL
LUTS
Storage symptoms
irritative symptoms of OAB
Voiding symptoms
slow stream, spraying, intermittency, hesitancy, strainning, terminal dribble
Post-micturitional symptoms
feeling of incomplete emptying and postmicturition dribbling CHONNAM NATIONAL UNIVERSITY HOSPITAL
Irritative symptoms commonly associate with VD
α -blockers in women suffering from obstructed urine flow
Non specific symptoms of bladder outlet obstruction, irritative or obstructive
Anticholinergics alone nor the combination treatment have not been studied in female VD Combination with α-adrenergic blocker with anticholinergics investigated in male
Pischedda A et al. Urol Int 2005; 74:256-61.
Kessler TM et al. J Urol 2006; 176:1487-92.
Athanasopoulos A et al. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:217-22.
CHONNAM NATIONAL UNIVERSITY HOSPITAL