cn.f1cn. 502(Clerkship in General Surgery and

Surgical Specialties)

~ w ~ ~fll fl1GJflff~ CJf1'1ff ~'j flW ~ U vrVl CJf1'1ff ~'j

lJ111i'Vl CJl~CJ~~CJ~ 1lnJ

iIlfj'rUJ (Overview)

1. tlmh (Introduction)

1.1 til\hOflfllUJ'UMf,(l1flQftlClfl'i(Definition of UDS)

1.2 ..rllU~;'IltHfll1ml~m~f,(11ftaftlClfl{(Indication for UDS)

1.3 J)n::IlYnO~1l\l~lOm1flll~m~fJhl'tnfllClfl{(CompUcation from UDS)

2. Ol1lI'11u'lr1ibu(Patient preparation)

2.1 m1I\1l1U'lf11Ilo::m1C11\lllllm1::(Unison enema)

2.2 fll1',"unJa;h\l::I';;tJ{jll~n'llfl119im~tl(Antibiotic prophylaxis)

2.3 nl'llMr1\J1Um,n\lfll1flllll (Patient position)

3. fll1Ifl1U'l,"1l~1'I1l~m~f,(hl'tnftlClfl{(Urodynamic room preparation)

" l' )3.11l11~fl11~nHf,(1l'tnftlQ'm (Urodynamlc room

3.211t.lfl1otm,n\lm1flll\lm~fJhl'tnftlClfl{ (Urodynamic equlpments)

41'3.3 "\I"'IltHm1mlllm~fJ 1'YtnftlQ'm(Types of UDS)

4. fll1ml~m-tf,(h'YtnftlQ'fli~1't.I(Conventional UDS)

4.1 Ol1'lfiA1UJCll'l11U'IlIHfll1cl!JifllCln::(Uroflowmetry)

4.2 fll1flll~fll1TiHl\I'Il!l~fl1::Il'tl::ifClCln::(Cystometry)

4.3 fll1flllllfll1TiHl\I'Il!l~o6'1'lI~tJ\l3••m!J'Illlfl(Electromyography)

5. fll1flllllm~fJhl'tatllQ'fli'l'llr1\Jlu~jjJ)n:: Stress urinary incontinence

6. fll1flll~m~f,(h'YtnftlQ'flll\lr1\Jl!J~jjml:: Overactive bladder

7. fll1ml\lm~fJl1ftaftlQ'flll\lr1ib!J~jjJ)n:: Pelvic organ prolapse

8. m1flll\lm~fJh'YtntllClflll\l~\Jl!Jllil~fll1,.hf1"Hysterectomy

9. fll1ml\lm~f,(hl'tntlltTI'I1l'llr1\Jl!Jlla~m1'~ltl Pelvic radiation

10. tlnQ'lU (Conclusion)

1

2

1. umh (Introduction)• •

UI)~u\J illLff't1viifl111Jfmdit11l1Jtl\J 1"ii/nou nl1Ufflfl 1:: ~~ Un9i (voiding

dysfunction) 1Jln~\J I)::l,.'l\J1A'Illn~i11V~1J1911ll) A'lVUty'tllnl1U lTl'm:: ~91Un9iii ~1\J l'Ul~1J

.1 ~...... ".J.~ •. 1 l' oJ",. ""'" .1 I d -,1'''-1Jln~\J 1l1J'IHHM1'U 11)Vl1N 01 lllfll1 Vl1lfiVlnU 1f111l~~1\J'Un1JU11Jlill1Jln~'U()VNl'tl 'U lWll~. .'I'll'lhmnlVn'IJUnHl'U 1Jlil

i ...J[' d. ~ .••.•.•• I .:. 4 ~

\Jn 11~lLn1n\llf;jillV'I'11Jll'llvUty'tllm1illfffll::Hli\U n91191Vll"r'tl::()Vl~Mf1() fin:: n n'U. .

Untlll:: hj~A' (urinary incontinence) u'U \J()fil'tlUOl)lnfl1l1Ji'l'1l~f\'1\Jm1ointh:19i 911lll

;l~mv m11U\1/J lLa::m1i'n\lllL~1 f11l1Jrm~A'l\J\! h'l'll'llllff9l5 (urodynamics) ~u'IJift"hii

t11l1Jt;,fity~ om11U I)\1Vnmaonu'U lm~ 011 i'n\ll ILt'I::m19i919ll1JHt1m;~m1 i' n\ll 1fHJlllVll::

()(h~il~i\J'lv~ii()lmmn:: ()1m, u1'191~~1ioifll1l'U(atypical presentations) ;~jjf11l1J~lLil'U~

• •lL"r'tl1VIl::~o~iiflll1JrYl\J!1'UliivlnUm1911lnlH\! 1nnlfnlT9If (basic urodynamic study) HIIlv 9~1l::1'l11Jl'tl hl'm1i'n\ll6ibv 'li'\'()dN~~t'/fl

l.ll'il~hnflfll11J'lJ6~gh'l'lgftll:/91i (Definition of urodynamlcs)

II1''1'1Mll'l91f (urodynamics) 'tl1Jlvii~ m1ffml1l~Vl0'IJmnil~1'U"()~fl1::L'I'I1::

•UlTffn::'Ii~'I'11~1I1'Um1tifll~u (storage function) ILt'I::nnrll/JUlll'lll:: (voiding

function) ~flU'::ff~fi''tllin~()~mHI1llll1 hmlftltl91f (Urodynarnic Study: UDS) ~

L~vIA'()~m'91IJ'lJti ltll1Jl~Vlfi'IJnnlil~ l'U~~flU n~,,() ~1::'IJ'lJm1 rll/JU\'ll'lll:: i\J6i11V

191viif1ll1J*'tl i~'Ill 01191nil\! 1, VlMl rr91flLfffl~ilty'tll" ()~~i11/JIJ()n1J1'1ll11l1it'll 'I\J

~ilI::~'lilm'91nll (reproduce patients' problem)'" ..; • u ~ " :'i I. '" .:t"ann11Tl 'Il!I1'1lifl flty 3 ,11::1111'Il1111'1l11U1'Il1ll1911l\lij 11'1Oftl GfI11JR-nl

I. m, 91'11l~~1ilTl1JmllLrrf1~()lm1 ~~li\Un9i'IJIH~U1VO()n1J1i\J"\lI:: 91n Il, .

flt'lm191nllli~fi'il ()lll ~1it"n1JnmlllJ1U1::ntJUnn1UIl\1V 1'f1 i'U~i11/JM2. fl119l1lll i1i'l'l'IJfl111J~f1Un9i'IJilI::lilfl1'91111l11l'1'1t'1tllrr91{~1ii~'tl1J1Vfl1l1J

•1lf11l1Jflli\Un9hi'U Il::11iiii 'Um, rllVU lTffl::'IJ!H~i11v

Q .1 Q ,.I i.f 'I '3. mllJHflun91'IJ1~()Vl~'I'19l11\l"r't'IJ 'U'lJUI::lllm191n\l11l~1! 7'\'Hlflll'l911()lll

i1iiit11l1Jnlti'tyhnmflniin (clinically significant)

1.2 ",,,u~;'lJtJ~m,mlll\lhfjQfllal'li' (Indication for urodynamic study)

1'I11J~lUU::~tl51flQ'UGood urodynamics practices 2002

- Patients in whom potential therapy may be hazardous where one would

want to be sure of the correct diagnosis before instituting therapy

- Patients with recurrent incontinence in whom surgery is planned

- Patients with incontinence and a confusing mix of stress and urge

symptoms and those with associated voiding problems

- Patients with neurologic disorders and those with a mismatch between

symptoms and clinical findings

- Patients with LUTS suggestive of bladder outlet obstruction

- Patients with persistent LUTS despite presumed appropriate therapy

- Patients with LUTS who have both obstructive and marked instability

symptoms

- Patients with obstructive LUTS and neurologic disease

- Young men with LUTS

- All neurologically impaired patients who have neurogenic bladder

dysfunction

- Children with daytime urgency and urge incontinence

- Children with persistent diurnal enuresis

- Children with spinal dysraphism

t;'M1'tJ~t'h{l~jitm::fllfu1Jffffl1::1li11'\''lfUI'Istress urinary incontinence•

(SUI) uU~lL\.'IU';V~1\'\'1'tJfl15I'1n~m~~hVHl!'ilffl'l{nvuhl'flmh9il'li' ml1l'lnfluM;v1li iJ~I\.'lu~l1miilHfiuvQvdl~h~m1J ~lfljjn15;jmnfjtJ11 tnnilfl1Wln~YlH~

•hVHlflll1l'1{nvunmh9iwril mid-urethra! sling 'un~1J~t'h{l SUI ~~9iv1tlQ

I. Vl~l••.hritJMiv1J1nn11 53lJ

2. tllIJ1l'hritJMiv1J1nn1129 iJil1JritJjjtl5::i~'lJv~ previous incontinence

Surgery

3

3. mqlvhihmifJIJlnn11 36 iJi'11oujjfln::UlTlTl1::vvummfiu (nocturia)

1Uf111111llu~v~~I;jUU~llllTUtl11fJ1~'~jjf11111~111'lu~tl~nlm~~n~ 1u~ihuSUI 'll011/J/Jm~ull9in/J~ihh::1~ tllm5 fJ1m'llrr~~ 1l11::m~PI'1~iHm/J,~,y~I~U

•.. . . ,.,»itl'~f1Hhl~H11l n11li~~ihufijjf11111lii/J~lJ~9ivnmh9i~i'mn (high risk) lvhlTu

1.3 I1n::lltl1n.811lllOm1f1111ln1~gT'l'tt:lt11crl'li (Complications from UDS)

fl11::llmnoU'tlu~fJ1~l'IuMullm'liuunrr11::'~lllln (urinary retention),

UrrtTl1::11'lulntlfl(hematuria), m5~f1I~v1uvml~UUlTlTl1::(urinary tract

infection), nmnflfl11::~I~un11 autonomic dysreflexia, 11lmn.hfl 1l1l::~'I'lU'~UlJ/J. ,~fitlm5~fll';vl~101::11lTlnllfl(bacterial sepsis) jj~'lu~lU111u~ihmUl»11uljjj

11n:: pyuria jjm ll1li'iu~~~::lnflfl11::IIm noNllu»"n~m, m1~'l1H~h'l'llltll rr~,"1~11lfln111Jn~

2. nl1!1'l1t1lJ~ihtl (Patient preparation)

1~uvh'tJl'lli!l11m,m1~'l1H~ hl'llli'lllT9I' 11'lunmln~~ invasive jjfhH~l/J

titlU~HlJ~Ht"lll1 um'~'1~111n ll1''l16~nlm'91''~ ~::~!l~jjml11!lfl'l1Uiiml1l111ll::jjml11. ,'lilulq)1Um~nln l~PI~1~1l1l::n" 11tJllF-lllUHtli'm 1'1'lU11Hll~ll~nl' ~~1~fi' #ii~1#ln11li'liiflnmtJ~/JUlltJMm,i'mn Ill'll1A'~lnjjn"ffmnl'lu11 urodynamic status '~lT1111tln1u1/J

Hllm,i' n1l1~tl~U1Tolteradine- ER 1U~ih/J~ jjII1m~~tl~01::1'l'l1::Urrlll1::um; l' 1lnu tJn~

(Oeractive bladder) M1 ""4'J: "' .• , 1 ~ 4 ~ ~4m~m1~'l1l~~ ~'I'lllffllT~nli'tllll::\'IHllllJ'U'l1U1'l'ltl~ ~::~Il~l1m'VllUl/J'1im,~,,~

,fu~tl'U9i1~'1fl11::11m n~vu ~v~lnfl;f'U,#I1li'lln~ihum1u nvu nlO11m 1~ t11111i'11jj ll~tl~

~ih/J 1l1'l::m~1~fl1111atlll1~OU~,hu'#I~::n11li'mMm,iu ~Ii/J~\ln~ll~~~~::jjHl'I9i!lm,

i'n1l1~~1/J1li'»lu9ill'tJ

2.1 0l111'11t1lJ~1I1t:1::m1lr111qIl1l11::(Unison enema)•H'~1IJlT111l~tli'utJ,:: 'l1lUII1»1' MPl111tlfl~nv'UIIll::mi'ni1f1" 91~1~UlHli'~III~•

• II ,., It • •

IIU::1.il1li'1'If1fll~f1lJlhMl~f1UVIJ(minor fluid restriction) li~iltVlv»lif1lliu~f1l1Iiifljj

" • .I • 1~ _I 'J:.l 1 ,:,'_1fl11::diureSIS ~lU::YIln"f1n~'1f~lll~~::'l1l»m'llullHllfll'91n~ \'IU1n~w flIJ111u

4

5

•~z1l1'~thvn'1ulluu11zYi~ (unison enema) lJ1U1n1i'luvvmYvmivm'hnni'lnu

thZlJllll 6 i11m l~v1l1' rectum hjiilluu11zlll'lzll.iiinnij1J"'1'Uv~ rectum lJ1mnuhJ

2.2 n111ti'fJltlij;huzl;iv\lv~n'llm,Qi~I~!l (Antibiotic prophylaxis). .

,m 1l1'v1t1ii;huzn~!l,'jv~rium1~i'lI;iv (antibiotic prophylaxis) nVUn11m 1U

l1HQhYHlff1n'i'l{U~I~U'l.ii:H'vi'ln<l~I~u~!ltiu vu li'lmlll'llZVv1~t~1U11lJ~H<lnn•i'ln~iJn'n'11z11n~ m1 1l1'lJltli);1uznvunn m1UUU'll.iiimllJ h~uVVH h~mlJ

m,1..r antibiotic prophylaxis tll\)ilfl"llJJlhfllJ!i'll~ih[J~ililnz.r~vitl't1~•

.. ~thlJhl'li1u1111uHi'l11n~ (cardiac valve abnormalities)

.. ~thlJl11~vvnl1iliiimf~Mi1J total joint replacement lJlillln'U 2 tJ

.. ~thlJ~iitl1d'~ prosthetic joint infection

- ~tblJ~jj geni tourinary prosthesis

y-'1 ••• "'".. 1jlJ1lJl1lJpacemaker

.. ~tblJ irnmunocompromised host, . .

lJltliFM1'UzYi1i'u'Ulin 1l1'1'U,t1i1Jtln:l11'U lJm~uu9i~11tliiu1111~Vl~~11i'l'U"'V~1l1'1i'l'UlJliili1lJl~1 l1't111mV1JtllJlJl~ml1Jf1liL1lJ~nVhtl 1ZlJ:::l1<11li1l1'Ju 'll.iuwuvu

lli1lJ'fi'1'ltl~z1l1''U1uhhn'U24-48 i11lJ~l1li~yhnmm~ jj~li1m1 syetematic

review vvnlJ1u81'i, nn1l1' antibiotic prophylaxis ~:::n'llJ11(lnIi1Vm1nmnrl

bacteriuria mi~yhm1m1~Mii~~vlJ<lz 40

2.3 nl'Uv~~tJ'J[J~H1'1lnml''J\l (Patient position)" .Inn'llJn(llilm1m1~1~i"'1n'h(ju yhu~ un:::'I'h'Uv'UyhYiH1'Un11rl11~tl111t1mil

~n'1JllJ ~tJ1lJn'llJ11(l'l'1'Uv~'milif'l~u1'U 1rlmlll'll:::vv1~t~~tJ1lJ~,r~ 'l.i'l~ Vl~~11t1u~mH'Vi,UV'll l,jv~U1nm1m 1um~~ 1Hi <lff1n'i'l{il'l'Um1m1u~HI1m'U lUVVH

, .... ""UVlJ 1-2 i'11lJ~ un:::V1~'U1U n"hl1'U1'U11lJYilJ1n.lVnn1ij~I!IJl'i'1111ii~li\hfii1Jlil'j1i1t1111i1nU1u~m~ri1JVlm1thfi(\J'Uv~H'thlJ

• •lrllJ~1 '1t1~I;jlJulinli1nnm1~ 1'U'Vil,r~1~lJ~lnHil~iJ1lJti1li~,r~ri1lJiJn'11::: un:::JJ ..., tI •••

lJ1~tli ~V 1~~11~n~'Vi111~II<I:::'Vi1'UV U1U H'tJ11J111Jl~lJ1ti'Un ~iiu 81u.l t111lJ~11i'lU.Ivn 11•

9

lUI! WltiflLllflUUIHt ~lJJlJLIJmu.w ~ttlll• b "" n. "'" I'

::tljjJ:!I1IlIl~~ ~lJJllllMmIJln.L11~~ll!lllLlI'!~lfjNll.llt ~lJJ~O!{N1J:!mUlJ' (lU.tl (f•••- I' ,..., ,~ /'l. ~

"~\~UlJJtQ.,\lLH!l,Unll Jl!ll!lIHlI,I~ 1il~ll\~LW ~LU~ wfl1m}!lL!l

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11}l\l~J[m~l'l~nlt fl,N~Ut 0,lt::& nll~\!~L LliltOAl(SlJUJI1JU) ~~~ r\~lftl. !:!&lILHLUl1ljlJJ~i< ' ,

,\\tn~~wo~u ~~il!ll1l'JUUIl!tt, ~tUHLUNl\\lfl::~ ~~~Ul~ rlWI1 W1Hlll::tlLJnytQ.~

lLU(J f\I'lt,I::LlllOt,ul'lk!nl~l!' JJ!lU lJJ8;lJJL!~~(l~ltll;fi W.i~lJJ1!LlILlI.\L1i'itLLl~ulJJ~0Al

(moo.l J!lllllll,\(lO.IO) }lJJJ:!llJlmLlfjllt~l,\tQA\ \'£

I'lL,\1~LLl,\~Q,l'n ll~ l ~lJJl'l~j::LlI'lLm b ~ 1,rll! ftLlli

,11 l LLli r ~l LIM llJJ!!,'lPOlILLl; um (J I\,~~IL!lfll Lli(J ~jQl'l[!}lJJ.lllJ.il!tAL1iltlll&t LlilUlAI

(11U!lll.ll1lla.ld 11100.1.l!IIlCII.\(lO.IO) lltLl,\Nl,\Utrl~l,\ltlU T

I'lt!fL~Ul'lll,il(JIlI11IO,\ IUI1(lISJJp10A1Sod) H,\'Q~l-ll::f.ll!Jl(J;

~~~\ftLL (lIo!l!sod alilll!S) rl'l~H\Ff.lJl)jGl'll~!:!~It1!L~ud\ (dAUO) l'l~t!jLHl[,LlULlJJ2If • • •

(xUIlI0) lOin l! 11Ht, LlLIL~lJJ.\lU::G1I011lsod alllllUl1bs l~l n t ~LlJl)j[!l'll P tlU l~rulrLJ, t~l

7

iJl'fl'f11~1l11~m~l'yn~iJIYln1~(cystourethroscopy) Ull::fll7~71HIlUl'J (per vaginal• !II ,. •

examination) u~~umm"v~l'Y;lJl~uYi1m1ll11'Utfli v~llllm l'lfl1f11i'",V (filflii 1)

~~fflfif\JDm.h~fll~tiVfmjHH1~fflll1' Ul1Jm~ibu lfI~ll~'lbm~'Jull~amr~ 11'.1',uu •

,. I ~ •• !II

l1',H1J1Ul1~l1'v~ltliivuLii'!lHlfhnu il~fflfilYYi'Jlfl'hi'li\'I'liunuUWl l'~171lJl~lhn 171'1•

fl11lJrrllJl~t1'Jll~fll~cilvurrrr11:: (urof1owmetry) 1ul1'vnJ 1'1i\'~lvull~iirrfllflU1f1ftVlJ

~rim.j,rNrrlJ~1~ll~Yil~1J1~1ntl~~rrlJnmu 'Jll~~I~IJUl'lU11~iburr~1ii1llfllrr~~::cillJ

Ut'lrr11~'hilllln lf1vlJt'lltl1i'j~lnfl11lJtI~::m,h1U7::111Hl'hfllHln~111~Q1~l'lMlrr~{'lf1

lJ1nn11Hibv'II1V•

3.2 qtlO~Wm,nllm~m1\lg hl'ltl II1DWi'(Urodynamic equipments)

Qtlm w1um~ \1l~W\'11~Q1~l'l" I'llrr~{lJll~i\',vnWl1111IJlJONI'hw1myihlfllUl'i ~"* Ir]YI o'ilo ~ & Q,I 0 4

Ull::III~llW111VIfI~1VUl'l'l1IJN'I11n1~~~1~fl1~f1n1Jlll~1111nnl~ '11N1'J'IIlJ~1fI~ll~m 1~•flllmn 1~rr!JU~Lm1l1'v~1Ul1'Ill'l'mrlllJ1~~1'JllQ\1l11llfili1vmnQtlmw~ '~t'llJ1J~W!Jl~

• •lh1l1'l'hm~m1~ 'l~'i\' l1illm1~ 'l.1'rilYi'1~f1HnUfI11lJlnU~1~1wHihlJnuuu'1 ril•. ..lJl\1l~jl'J'J!J~lfli!l~m1~iinmhl1ufI Hfi~iJ (I'mHn 1)

. ._1'VO'!'l'.'l i '''v,,~1J01Wl1ilf11ll'lllllm,~, 1\lllHg 1'I'11l1l111'mlJA~1l

.- Cystometry transduc.ers (fIll'lii 2)

1~Wnll1Uflri1aNiJ~~0 (Zero point) H~~::~U'UVUUlJ'Ull~pubic

symphysis 'JlH~ibv nlJQtlmlli'1f1f1nl'h~lU'll!J~m::Ll'l1::Ul1'l1'11~lf1IJl'hm~

1f1rimH~U~fflfilYfi~'; lJi tici'

- Intravesical pressure (Pves)

nlJuH~U 1Um:: Ll'l1::Ut'lt'l11::umhmnu cmH20 lf1IJ1f1~lnt'llV~hil,rl

1uIn ::I'm:: Ull' l'f11::

- Intraabdominal preSSl!re (Pabd)

tivuH~i\j1u'lilJnrlJ~umi,m1Ju cm H20 l'liunw lf1IJ1f1~lnl1'11J~1lYl,r1

1m;1'lff\1lHlY1UUUupper rectum

- Detrusor pressure (Pdet)

flVU 1~.Jjj~lfi.,~1i1i111uml1'J!Hf11 ::lvndJ ,Hn1::~~iil11.hmi'JtJ emH20

vm'li1.HltJ ri1~'!A'~1i1i1ml11J1'W1'1mt1~!J~.J1lnJi111 Pdet : Pves - Pabd

. .<OIl , ~ v t'

~11Nl)...lllrr~~m'lJl~1! 1UltJV~~U'IJ!Hfll1I!i:I~~~H'I'IJ!l~fll1~11\lnHIlI1Vmrl1i:lm~m

filllU::U1'IJ!HInternational Continence Society (ICS)

8

Accuracy xl em H20 for pressure

x5% for the full scale for flow

Detection range o to 250 em H20 for pressure

I o to 50 ml/see for flow

o to 1000 ml for volume

Time constant 0.75 seconds

Soft ware No loss of data for pressures up to 250 em H20 and flow up

to 50 ml/see,

Frequency Analog/digital frequency of 10Hz per channel--

20 kHz minimum may be needed for EMG

Printout Line resolution better than 0.10 mm

Maximum deflexion:

Pressure 200 em H2Of-.

Flow 50 ml/see

I Volume 1000 ml.IMinimum scaling:

Pressure 50 em H20 per cm

Time 1a mllsee per em

I Axis I min/em or 5 see/mm for filling

I [!:e/mm for voiding

- Catheters

Transureth,'al double-lumen catheter (nmn3)

li'/Ulf1UVlnUllwnj!lU jjtliJ'1~tll11U1nU 2 t 11111flJidJll'lhlft::1'1

m~l'luhJf1n!\'n::iJlflfl1:: (Vesical pressure: Pves) lf11JjJU1'11~1li!'1i1tl6

Fr u.i~UU)JH'lt1'ltlf1011'1()'IJU1'1 8 Fr

Transurethral triple-lumen catheter (il1'1'l~3)

I~Ulf1U;)nU)1IrrlJ~jjt!iJ'1~tll11U 3 t 1T1lIflJidJ1l'U1 1'1m ~1'l1Jlu

m ::n'n::tJ I1'lfll~ (Pves) llll:: 1'1111~~u i Uli 11iJl1'11'11::iJ11'11'11~

Suprapubic two single-lumen catheters

UU)! Hi u > lU~jj 1111A lJiu 'II11~11!liJlflf11~ (Urethral stricture) 1110d'J u

Ull:: lf1U1'1 Pves I lf1U

Suprapubic one double-lumen catheter

li'ljAlf1U\:;lfllJ11'1lm()i dlflUl.,J1m ::lvn::tJlf 11'11::1'1U Hillilllnfh lJ

ihmr~'lfU'1percutaneous placement

Intrarectal halloon catheter (IllHfl 3)

lijUfl1()~ii balloon 1ihil,]11u rectal lumen !liD111'1,il Pabd

Illl'liL2 Cystomctric transducers

9

10

11mn 3 lUIi'll (1) Triple-lumen eathcler. (2) Douhfc-lullIcn catheter. (3)

Intrarectal halloon cathcter. (4) E"IG skin patch elcctrodes 'lIld

ground, (5) E:\IG necdle c1ew'odes

- Flowmeter (nmn 4)

il(Jql.Jm Illi'ltnllJffl,m ()tll'lfil(JtJlYlfll~ (urollowmclry) iJI'I"WrllJ -' 'liU'I

Gravimctric nowmctcr, . .

IIltll'llfln 11¥IUOl'Hl1\.11\.1~l 011111WO'UO1111\1 ri l(JtJlYlYll~ aeo lJ1

Electronic dipstick nowmetcl"

111tll'l1'1n1 lflUtll;lhtnlJU10 electrical capacitance U1tl dipstick

mounled hJ collecting chamber

Rotating disk nowmetcr

1111ll'll'llil1 '1(JOl1ri1U1\.1~lml i l~;;\'tJ 11'111\; Tl1I11lJ\.l rotati n l.:disk '11m, -" ••••• > ","~ ~"'l.'f vfll1lJl 'l111111'li1IHlU'UlHull'11\Wl-IIlf IIIuTI~U\j

""m)1" Flowmeter

- Electromyognwhv cquijJl11ent

•o<!:i ~I ~ ~ v ~ "'" ""-11 "" "'",HJllumrum 1\Jf111illll1J 'IJ~~f1I1liJ!jJ01'IfJ11,ltJ (EMG) lNl1V11'U;mJ'if'W~1

1V" 1'J1 ~ ""y,,. ),'V I •••

11lftflr1. 'ifmlJf1111H11lJl~ITlJ Ii! ~1\J1rllJ'\Hl'1tlft~ 1!1):i! OVHClnl'11~mJ

Self-adlll'sive skin patch electrodes (I1mn 3)

irnul'JlJlm1'lhU!~nl~1)g IrlH'il/J jJ'1Al\lfl .umcrvHn fi1~r~'li1'i1flllJJ. ". . ~' ,I~~e \1' """ 'JI ~QjJ

tJWIIO(Hlm Wl~0 1\; .lJI'I'!1f1'Ut1t11lJllJ~11V1D1fll,.11 )\J

"Needle electrodes (l111'm3)A 1v, V'j ..dod.... , jI ~

lWlJ 'if .w~i.IVmJD 11ll1'l1ltJl !ltl1 perineum DQIHll ~lllJ~\Jln electrodes•

A "'l'J1'=' a,l ~1:i1 ~l' , """'" '1'1"'II'W'1mll l!!n\1f1TJlJI~'Uu1~.'1 !!fIt ,mr~mn\'10fll'!'\IV1Jlllll'ltnl ,nelll!

ih lV~ll1H 1l1VIllJUUl.IUlJ~ ~1l111HnJ1Jv11'1 fll'j'" I!n~f)llll tJ nt-mlJmoil

IltJ1Jmn

1 i

12

Wire electrodes

4 " •• ~ '4 .! • 'JlJ'Jl1lJ'Jn1IJfHHn'tJ needle electrodes 1l1'llJf1111Jstahle mn'lJ'u r;jlllJ

tnlJml~tJ'1J'l111.1'll'1lJ~ electrodes 'hjlfl~Oljl1 ~VII~I'I

3.3 lluYl'U!l~m1ml\)m~gh'YH1f'11il'Y1i (Types of UDS)

1 " 11" ", Q ••nnml~l11~Q nH'ff1rrmV1~llm .Uu\Jl1ft1tJ'lf\JI'II1V

- Eye ball urodynamic study

fiv m1ml~'I11~Q h'Wftfl1rrVl{11.l~'Jmn'l ~tJ~hiiJQumwv\Ji'tJofiolH!UmW, .YiHiJ1Y;1J~Foley catheter, syringe glasses 50 mlllft~ rrl1J1J1~m1I'1n~ihl1lJ1~tlu

~1J11J~L11ilJ~o~nm 1IJfl~l~lJl'Ill1mJn L'W11~li11.1'~11J.uolirlJn0f111lJ11ll~o(iO~lUft~

'hJtT1lJ11(J1f1til Pabd '1.1'

- Conventional urodynamic study (UDS)

1~\Jm1I'1n~lmQ 11lH'1l~ltTl'I{~mUmlJlJ1m jJ 1\J1\JiJ~~u\J iJm1lt~\J'i~U'tJ

son ware 1\J'JOlJl1l1I'lo{iJrrllJ'; moU1tl'tJoumw nl11'1'il~l1n'lfUI'I ~v~u Ml~ f.lfllim~11• ••

multichannel jjmml~ urof1owmetry, cystometry, electromyography o~~i'1lJtl\J

l!lJI'I (m'W~ 5) iJ~~U\JiJ'llUI'I~lhjiJrr11J~V'i~I1'h~Lf1~!Nllft~UVlllHl~f.lft(wireless) ~~4 .1lJfl11lJff~I'll nm n~\j

- Video-urodynamic study (VUDS) (i1m~ 1)

fiVm11'111Ul11~Q111'It1f'11rrl'l{~iJm1n1IJm'W'lJo~lower urinary tract system

'hlJ.I'llJ 11'1IJiJ'lumw~uilJ~mJ1iiv Fluoroscopy linl~\j'llWf1 C-arm u~iJl1nJ. ,

11fi ,m'h\( ~hll11'i n11Jfl1VIl\00~nml'h.j 'i~IJ~ rrm.hYil ofi'?I'o~jjl11mrrlJ water soluble•

contrast media #lllJ oUo~'lJv~l~iJMiv l#1n1\J anatomy llft~m1'tJ function 111, .

l'I10lJ'lr1\J un HhmlJl1JJnl'ilwlllJlJln .umiMio 11~Il'WmJllft~~1J1IJ01U1#1~'tJ1~ff[I'IIJ•'hjh~\J

- Ambulatory urodynamic study (AUDS).• 1...... .....~ ~ ,..r.t~110l11'i1'1nUll1~Q 'il'iftff1rrl'l'ill'tJ'tJl1nl'lll'll'll'11lJ'IJ\j1'i1lftnllft~l'tJ1'lJOl'lflVfflm'i(J

hrm11U~lllJlm llJ~1J1n11.1' oUl'lllYlJnvllU,mftm11'1'il~lJln lffIJ1111J~11Jll,dh 1llllll'Il

iJ~~,j1JiJ~l1'J1J~(lflllilJ~n1J1J~'wd'IJ I'l~U1~llJ'lfwl \j 1111f11Hln

.-l • .•IflHl1'\Jf)~ Janus UroVISlOlI

ll.mlii Cystomctric equipmcnt

~, Ill1V1TJl1mwhl'HlflHT\'I{,y./ltJ (Corncntiollal UDS)•

fl171'l7l~~lNU 'bYH'I'IlMl{lr'j 'I iJ (conventional urodvnarnic studY) ~::m~ll1'l$\'';oJiit1. ""•D'I1'oul 'lilH 1117A7 1~ 11n1 ~ 1III (VmVI~'l11~ '\;;1\11 III 1vii U lV T~Ul'1tI8V~lI<l~ 'hH'ml'J llJUU VfJJJ.,

"'..'1 ?I ~ ~ :,J.' iI~lflf;!U"'UlUll \1i7UU7eUII"1

~,l flnmlilm1lJI1HJ1HI'U!l1fll~ri11Ji1if1Tl1~(UrofiO\\'lllctry). .~l •.. ,... ~03 ~ i-' .••• I ~ ,~~u7~lf~IHil1f1'l1J~fl~-,;nliJUflllHljlf)1fl11m 1~111!'l111Hl~1tl\'l~1O~flnmu

tJlflfll~ (voiding dysfun<:tionl lruill~l:rll'i91n~~i'l() n~l~h'hjrl1Ulfl md]

.1 ''', ~ .' v . '1''1 ~ v 'j ~u'i:::1~91\JIUfl1'ill~ll'iml1Hl1m~ (screCnIlH! test) ,I~~ 'Ii Wl11,1~~lllJH11~t1"1- .

13

14

m,fmn (follow up) li1 hwhr~"hvmfuull'll'n::~uu1~I~lJ~1lt\'1utrll'n::1riltl~~lJ

t'i1Htl~lJ~flowmeter ltlv1u~"hvll'~i,jm~unml'1~ iurh,r~ (sitting position)

mUlJU'J1lI::I~1,r~in 1t11n til ~M~lnm~~ n~I~UAl'lnlJ'J lJ~m~ li1~1U'J lJ~01:: 1m::

UI'1ll'11::(detrusor function) ull::m~lJlJn'JlJ~m::L'Yf1::Ull'll'11:: (bladder outlet)• •

Uroflowmetry ;; j;\ ll'llJmnhlJ1U UI'lAll'ftfmiill1U1T1T11::ill 01::1rn:: U1T1T11::• ••

lJVHll'lJV 150 m1 njlJ~~1n':huilJ11l1U1UlTlTn::l!ujjAlln1Jt111lJm ~'J!Hnl1i:J1T1T11::...',I'~' . v :; .1 ',1' ~ ~ ,1- >1 .•111mllll lJ \'ttl1~mm7~'1~lJVNU!W 2 tlH'JU u nlJnllmn"lJ~lJ11l1ulTtr11::mlllJ

catheterization)

....:.~ ~ 4",";IHnI11YI!NUUUNllllln uroflowmetry litH'll

- Flow pattern

..lNormal flow pattern (iIl1'in 6)'. ,~ *1 ••• .!:.cl I 4. , I ••• ......" ..,.

t11711111~lJ7::,.HtllllJtllllJ~lJllllJ~ lJ'lJl~1T1VIJ curve 'ImvmlJV Ull::lJ",;..1. d... ..:..

t1lllJU7 ~lVilJ'JlllJV~~1~17ll1l'H~lm ~lJtllVUITlTll::

Intermittent flow pattern (iIl1'i~7)

jjlinlllll::'IJlJ~ flow ~U'1iW] hjjjt11llJmJUlJU limn~~lnmmj~';':w'JllI::

I"hVUfI'fI'll::(Abdominal straining) 111lJl~UAI'l~lnf111::m::lVil::UlTlTn::

ul'l::~~"rhnu'1i1h::1T1UnU (detrusor sphincter dyssynergia; DSD)..lObstructed flow pattern (iIl1'in 8)

jjcinlllll::'JlJ~ flow ~jjt111lJllH~1 HI1I'l11um'UfI'lTll::U1UUll::jjt111lJ

m ~1~IJ~U'li'll1ci~l~lJl"hvi:J1Tll'11::,jmn~~lnjjm~fl~~u~vi{)UlTlTll:: (urethral

obstruction) 111{)~fl{)01::l'Yfl::i:J1T1T11::(primary bladder neck obstruction;

PBNO) ~~ll'lUtl1l::~{)l~'YflJ 'Aiu~lhvlT~'i1J1mv

Overactive bladder flow pattern (sll'l'ln 9)

iicinlllll::fl~lvnll normal flow pattern U~il{)l~'Yfll'hjjt11llJm~'IJ!Hm~

UfI'fI'11::lJln m'Yf'IJ{)~flow d'lU,::'i7~fl111iiv~"lV l,j{)~~lnii time to, .

maximum flow rate ;h;un1lfluun~ ul'l::~::jj!J1m7 urgency 1llJ<Jhv

••••21

•• ••

15

'"a50

Qvoj1000

••••

••m11n 6 Normal flow pattern

11111~7 Intermittent flow pattern

'"

01:11

a50

0.011000

"''''01:1$

, , ,

/, ";0

.IIllnn 8 Obstructive now pattern

"'''' .."• " , ,

/ -, •• '" '"

---I11n~9 Overactive bladder now pattern

Q50

Qvol1000

Q50

OYOI1000

16

17

- Flow Parameters

Maximum flow rate (Qmax)

titltl11)J1L H lJ'~lf~~tl~ nl1 n1viln'n'11:: 'IIU1VflV ml/sec

ftl1Jn~iu~'lf1IJtitl ).I1n11 15 ml/sec i'Ua'91itiv )J1nn11 20 ml/sec

Average flow rate (Qave)

fiVfl11)JU Hl\1 av~V~fl17 n1vila'a'11:: mi1vti v ml/sec

ft11ln9ifiv )J111111110 ml/sec

Flow time

•• diY."l 'il :: , .•fl!ll1111'n "IJ l'Ufl1Hl1V a'a'11::'n~'II)J~ 'IIU1VflV seconds

ft11l119ifiv UVVI111 30 seconds

Time to maximum flow••• ••• ••••. I •••

flV::V::I1111u'Um:: 'n~fl~ ~~~V~V91nfl11)JU H lJ'~lf~ 'IIU 1Vfl v secondsI .1 ..••••

f11ul191flV 2-8 seconds

4.2 m-s91lltlm-SnH1'U'IlfJ~n-s::1'l11::ihl'1:rn:: (Cystometry)•

017 m 1 un" n1~ 1'U~V~m::L'Yl1::ill'lt!11:: (cystometry) tI Nfli' ~1711;VI111

• •cystometrogram (CMG) 1~v'ti1 11l0179171I)iJl)::m::n11~v01~ irin'lvm11)1;i'1 i'U

m::I'Yl1::ill'fl'fll:: (bladder catheter) ;1)Jntl017 irit!lVl'l11Ul;i'1 i'U'YI117'11UI1(rectal

catheter) l11Yii.fl 'Ufl1791111)JJIIItl \l l11J' ~'111Vl11\l V'U Uthl9l fl11)Jl'll)J1::ft ~i~t1l'h1

)J1Ud'1 i'U111;i'v~ 2.3 'Ifl;~l)lmf\l U::111fl1~irin11'11)Jl1flu1i~fl11I'lnurl'tlVllltl'U 2 'li1~

fitl storage phase (filling cystometry) 1L1l::'li1~voiding phase (pressure-flow

study) fl17 1)::liivl1Mfl11)Jfl'U iIlltl'UWL!'l'lJi 'U'li1~i'II'U~'UVdntl11 111n' ~nV11~ibvjjfl1~

• •n1viln'1'l11::il~lln9iltl'UlLtl1Jil'l lfl1tl~1'l71U i'Uill)~,j\lJJm 1)J0171'l711)'ti~ 2 'li1~1;i'1

~1vn'UL~vfl::~1n~tl017H~1\l (1ll'l1~ 10)

i-1I

)000_-'----*-.1J

III

•

tlrnn 10 ;",'ol"lnal"iueo-urodynamic study in a female adult

. . .l'l'11141i1H1u:ll1m1il (fill medium) lTf1l~I:tJ1~~n1l'1 (Sterile water) j1~n

18

. , .lhln~o (nl1nnaJ saline) nO\l!H.l1iJi1~I11~il~~ril'l'~, . .

. Slow (physiologic) fill: less than 10 mllmin

. Medium fill: 10-100 m!imin

- Rapid fill: more Than Ino rnlimin

lV. "'d~'IJ 'lV~ ,il11l\t till raTe l1n'Jlnj.J 1 01il\111l1lllYilow Cl1mp1Jancc H<lt small

cystornetric capacity ~1lhj'h.jil7~i~ hj~thvlT1'hJlJ1':;UlJ fill rate ~ 50 mllminll~> •

l11mlom1'jl1r'l1lJl~fflJ1JlIl~hm11l11H till rale i1 I 0'% 'Uo~ functional bladder

capacity

19

fll~1~,iM~66n~lalJ1~~~~

- Stora&e phase (filling cystometIy)

Bladder sensation: first desire to void (FDV)

normal desire to void (NOV)

strong desire to void (SDV)

urgency

Bladder capacity: maximwn cystometric capacity (MCC)

maximwn anesthetic capacity (MAC)

Bladder compliance: normal value is more than 12.5 mUcm H20

Bladder actvlly: detrusor overactivity (DO) is involuntary detrusor

Activity either spontaneously or with provocative maneuvers

Valsalva leak point pressure (VLPP)

Detrusor leak point pressure (DLPP)

- Vojding phase (pressure-flow study)

Premicturation pressure

Detrusor opening pressure

Opening time (OT)

Maximum flow rate (Qmax)

Average flow rate (Qave)

Detrusor pressure at maximum flow (PdetQmax)

Detrusor pressure at minimum flow (pdetQmln)

Maximum detrusor pressure (Pdetmax)

Posticturition contraction (afte •...contraction)

Post void residual (PVR)

m1u'l.lnFll\mHI1"l~cystometry 111JiniitJ~llJ'I1linICS Deflnltlon 2002

1~tJL"fI"lnltJ~llJHnn1191n~~lnstorage phase 9l1lJ~"ltJvoiding phase ii~iitJ'i1

m\J~':1'W

20

- Storage phase (filling cystomeUy)

Bladder function

Sensation: normal, increased, reduced, absent, non-specific, pain, urgency

Cystometric capacity: normal, low, high

Compliance: normal, decrease

Activity: stable or absent of DO

neurogenic DO (NDO), idiopathic DO (IDO)

phasic DO, terminal DO

Urethral function

Normal closure mechanism

Incompetence closure mechanism

Voiding phase (pressure-flow study)

Bladder function

Detrusor activity: normal, underactive, acontractile, areflexic

Urethral function

Normal

Abnormal: mechanical obstruction, overactivity, dysfunctional voiding,

detrusor sphincter dyssynergia (DSD), nonrelaxing urethral

sphincter dysfunction

nmil[JiJtlI'l1::~fltJn~ (voiding dysfunction) ~"UUfl[J jjflQ~1[Jfilll1f1l(Jfllm~

(symptom) lJlmmtlfl~ (sign) ll.,::nlL11~(condition) ~L;j[J1I~::1Jflnri11ii~L\l"1::

n(Jll::lli(Jfl1Jfl~m~m1~VIl~~1~"Mlff~{ll ~nll~~Il9ill::1~11imhofl itJ

4.3 0111'11111 011T1N 11l'!tl~nO'nJldll'J~~mIJUtl11(Electromyography)

tJn~m~'111111ill'lh~filling phase '\Jfl~fystometry lJ1f1V1l~I~lIiJffff11::l'hll

lIfln external urethral sphincter ~::jj tensi~n !JQill~::~Ul1i1~tension ci'~::fi!J[J'lL~1J

1Jln~u~lIii~'lh~ll~l~l[J'\J!J~m~iJl'lffl1::(end filling phase) Lrl!Jln~1JiJffff11::~G~il'

21

~:::mllm11vvn (sphincter relaxation) m::;tl'ndJI1'I1'11:::ii~l~lJjjw11 (detrusor. .

contraction) Ijj!lnmi1U11l1'ln1:::111'~~ill-J !ti"J~~:::iJl1l~lhJ.r1 (sphincter contraction). . .

l,j'l1nvlihn:::~1.Ji1~m1mi'l-J~!l~ filling phase onfli'~

fl1UJNmJnPi~'I'lu1.rjllnnmm;) Electromyography (EMG) ii1.rA~d

- Detrusor external sphincter dyssynergia (DESD) (illl'l~11)

~Ofll1:::~\1 ~'11111:::m:::m 1:::1111'11'11::;l'11~1U'hhh:::11'1Unl-JmlJiJn~ lfw hJiJnlJ

flillUI'1'1'IJV~'I;J~"J(sphincter relaxation) 1U'lJru:::~m:::m1:::tlI1'I1'11:::UU.'i'1irnl'11.J1l-J

~thurijJ infrapontine-suprasarcra! cord lesion

• • • • • • .~---J"

I. Vol1000

o50

Qvol1000

;;o'.es200

paM200

')Wln 11 Video-urodnamic study shows detrusor cxternal sphincter dyssynergia

(DES D) in a 50-year-old female paticnt who underwcnt hystercctomy 2 years ago .

. Delayed relaxation of external sphincter

flVill1:::~'l;Ji '11111:::n~ :::1m d:J 11'il11nl1 ~1U1111.11:::11'1UnUV11lJun1i 1fIvnl1l~ fllllU

1'1'1~v~\1iV1(delayed sphincter rclaxation) i'l 1l-J'lJru:::~m:::t1'Il:::tllYI1'11:::umi'1~11

hltf1"Jill1::: psuedo DESD irnl'HJ1l-J~thurilnu Parkinsonism

22

- Dysfunctional voiding

fltll1n::;;\1 'I:~lll1::m:: 1'l'l1::111'1l'l1,::l1H1\j hhJ 1::U1U nu~llJ 1.ln9i1fW11ijjn 11

f1111/l91,'lJtJ~lJ'I:~1\j'IJ1ll::~m::L'Yn::11uun::lhJ91, l11'»lii~I11,:: mlitJu DESD L!Yl

1'1.1 1 '1>'4 .. i ~ , ~i1 d.l ••~F;! ,/l 1.11'11.1neurological disease ~'1 lJn'l'i1J W;j ,m~n'YI1.l'l'i?ll\j1111Hn~

.,.itl9inn1.lN~1.ln9i(behavioral maldevelopment)

5. m1I'1n\ll1Hgh'l'laIl1111'1i'11-1~i1'lJ~iilln:: Stress urinary Incontinence

I1n:: Stress urinary incontinence (SUI) 'u~ih/ll1'~1 m\lJJu1I11ijlJnlnl11,:: Urethral

hypermobility M;V 111,:: Intrinsic sphincter deficiency (ISD) mh~'~vri1~Mi1~ M;tJi~ 2

111,::<J,lJn1-ll11Hn1~'l'i1JiluUl1::lg~11~\llmm 1v \lllJ M;!) increased intraabdominal

pressure 1u7::wh~1111~n~'YIHQ 11'l'lM1U~51~v~1lijj1111ij1J9i,'lJtJ~m::I'l'i1::11uUl1:: 111, .

17/lwh Urodynamic SUI (3t1n 14) 1111~11~iMJu1111V\jV1-l'h'Ii'''''lii~\l1111111::ilUl1'11::lg~-:,-'

11~~1111111ii1J9hH~1.ln9i (Detrusor overactivity )'lJV~m:: l'l'i1::11UU11::~Ii'i~ ~1n1111m:: ~u

~ll1nU'!) ~llJ (Stress-induced urinary incontinence) 1111~11~m~Qh'l'il1tnuI'l1'1fii~

ril/ll11'l'li'lJ~,/l (VUDS)

, iJ tI •11111UJ110I1U~SUI tl6m 1-14 1::IIl'YItlll

Type 0 - The patient complains of a typical history of stress incontinence, but no

urinary leakage is demonstrated during VUDS.

Type I - The bladder neck is closed at rest and situate above inferior margin of

pubic symphysis. During stress, the bladder neck and proximal urethra

open and descend less than 2 em.

Type IIA - The bladder neck is closed at rest and situated above the inferior

margin of pubic symphysis. During stress, the bladder neck and

proximal urethra open and there is rotational descent and characteristic

of cystourethrocele.

Type lIB - The bladder neck is closed at rest and situated at or below the

inferior margin of pubic symphysis. During stress, there mayor may

not be further descent but the proximal urethra opens.

Type III - The bladder neck and proximal urethra are open at rest. The proximal

urethra no longer functions as a sphincter.

nn>1~, ij1>1fil~n51h~11d.~~nfll1IJff1f1'l!i 'Un11% ij;lum,~ ISO fi~fln11>l~')ij1'lfil

Valsalva leak point pressure (VLPP) 1110!1UnBn~0l1i1rJ1Abdominal leak point. . "

pressure (ALPP) l!'UIO~l'I'Um(lm::1111'luiHNihu111 Valsalva maneuver 'U!l.I~YiihJ1i'U•

m::m1d:Jl'I'l'I'l,::th::lJllll 300- 350 mllltf,)111m~1'lfil Pves ~UOU~l'f'l~111MiHJl'I'l'I1,~I~'l.;

11'lflOnlJ1(mvl'll 12)

11111::1ili111utlm'H1n11m ,II~~~

Pves < 60 mm H20 l1lJ1UOlnm,~ ISO

Pves 60-90 rum H20 HlJ1u1i~equivocal study

rves> 90 mm H20 \1lJ1uii~'hjnm,:: ISO

I I.p~k I

L Vol1000

IIe130

lovol1002

'""

~,

I VLPP =30

ilm~ 12 Video-urodvnamic study shows VLI'P = 30 cm 1120 in a 47-year'-old- '.. '"

female patient who present with stress urinary iucontincnce,

24

Q-tip test> 30 degree \1lJ1U~~jjml~ urethral hypermobility

Q-tip test < 30 degree l1lJ1U()~'liij11l1~ urethral hypermobility•

~lflN<lf1lHln~li~ 21Ti.vl~.I"JOm;11l1'

I~UT1'll1'tllalJnll,"VIfm:rn1l1~l'I1lJl:anJlln~thtl SUI 1~uflihoON1'l11J

- ~thujj SUI 'lfij'Jli1'J~lflurethral hypermobility

flni'mn fin Retropubic suspension, mid urethral sling (TVT, TOT)

- ~thuij SUI 'lfij'Jli1'J~lfl ISD

f1l~i'rl1l1iivIntraurethral bulking injection. artificial urinary sphincter,

pubovaginal sling Il'lUJIU. '

hjiJ~~tr'Uilv~1lilJoU'vl'qlJ~lflprospective randomized controlled triallnVltllJ

,.h::;lV1iW'\l!J~f1l~Vl11~l'1NU11Vl<lrn"'l'l{llJ~"hu SUI ~ijolf1lml1~V1fll~I1"'V1~i''JI~U~1~tJ11•• •'\I!J;~u'U::;-wl1,r ";lf1l~Vl~1~IQ l'll::;m~~lU~MVll ~ffu1lJf1l~1,rf1l11Wmtu ~~iJ1milllJ lllll, iu

•<vii' ~c:s'11'\1!JflO'U\1'Ul'U

6. f11~mllJ'IlH{jln'HlI'11"'V1llu~lhtliijjJ1n::; Overactive bladder

11l1::;m:;IVlldJllllll::;lhJ~11l1i1'Ufinmiml1fll~'\IO~iJllfm~~lJl~ ~ (urgency) l1<lnm•ml'l1lJil1J!Jlf1l~fl"'UUllfl'll~ 'lli '1J1'l1wl1Iurge incontinence ui1~Vl~11lJ~llJfllJ nlf1l~iJllllll~

UOU(frequcncy) ui1~fll~llllllYJ~fli11~fiu (nocturia) VllJ'ltil'j~"hull~mi1~'l1lmlil'1nl1 fill

,.h::;lJllll 9-16% '\IlJ~1J1::;'lflmtiil1\lJ. "

Overactive bladdcr (OAR) Itlu symptom diagnosis II'lUlr,11J1l1lJ1H111rf1l11mn. ''j" ~ '1 ~QI "'" co.....<!l V 'j./ 1 4ltl IQ e?l v 0 '1 ~'Jl! i1l Vl~'\JflU1UIWL1Jll~VlUI1i11I1IV11!lJlJfl1llJ~lllJU.,o~mfll;<1 ~1~11NUInl Mil llVl~11fl• •, " .

~lvnou fll~ i'mnl1viM ~M'lli 11om11'U~lVtltJ!l1J111W'll'U1111UOIh~'\1~" llJi11~i'fl1JlliJO~i111Jn•fill lifc style interventions and oral medications

25

•,y!lti~;'UO~11111'111111VI11\lgh'l'latllaf11\'Il~ih!J 0 AB

• Failure of conservative and drug therapy and

- Have tried medication for at least 6-12 weeks course and

- Consider about more invasive treatments

~~th::ll'~ti'''lHm1ml~~ 11'1'll1ff111'f1{~I~!l~1l~m1111detrusor overactivity (DO) ~~'" w .1 ,.I. w 4 • ...l .; .I. i.t' w ~.~.. 411J'Illl'1llf9J1111n'IJlJ~OAB ~1J1::11'~f11111'1f1tylJnll(J1~m'l'l1l11111'11119J1l1l11111l1mnmn 11JII'lHl1~

ii~~li1t'lllhfillL11'1'ltJ':h DO iiflll1H1m;lInOU OAB wet 1J1nn11 OAB dry

DO a1m1ollti~1l1ln'~1i111 2 IltJUflll

- Phasic DO (1l1'1'l~13)

I. Vol1000

a50

avoi1000

P""200

pabd200

pdel200

EMG 150

IIm~ 13 Conventional urodynamic study Indicates phasic detrusor overactivity

In a 66-year-old female patient with lumbar spondylollthesis.

26

~#-LJ.,"""j•._------_._ •..•"'-------~!3;I ~<

I I I VOl___ 1000

L

IUI'ln 14 Video-urodynamic study indicates tenllilt:ll detrusor onractivity

in a 40-year-old female patient with overactive bladder symptoms.

/if! DO~lnl1l~wlhn:;l11)fl'ii.,! UU h.J lli lIing phase '111),(;y~tometry lJnm lUVIDllJ

~"h1J~lJm11Jr:Jl1Illn~'IIl'l~1~lJU1J1~11'l\liil1ltuU(neurological deticit)

- Terminal DO (nl1'ln 14)

flO DO ~tnl1l~\.lhdl~1~1t1'\Jl'l~ Ililling phasc l!alJJnmlJlnl'l',tlf1l1QWU11'11'11nlUll

lJM11'lIJVIUllj~"htl~n11111Jr:JmJfl~'IIl'l~1~UUlh:;11'111'lljil1l!ulj (no obvious neurological

deficit) l'llu\nJlw?i"h(J~lJ bladder outlct obstmction (BOO) ,'Jill ~1J1Jl1rl\\lJ1f11>1l1'J\Jc,\'lj. .

., ,

f1l1n<\,ljU11'11'1l~'lli'MiinU111JillJ pel\'ic organ prolapse !~'1fl1l:;111'1lJ'J.\'UtW 1m11'

11111111116incidence 'IIl'l~urinary incontinence ~1~lJ11lJfll'llJ1~1J1ru 10-58% unlit';

delinition '\Jl'l~nn~ml111f1~n~1J1J1~'IO,~"h1J 111il~'h~mlll'j 1\1U-J1 stress Urinal)'

incontinence JJnVllJlwcr"~01~lrD1Jii1l1Jf1f11~fl1Jrillj mixed and urge incolllinencc lJrl1'l1l

lljcr,,~~l1fJl~lJln~\.l risk factors 'liD, pclvic organ prolapse flO 0"11/f1mif~m'jr{ ullnufJ1,

27

~ ~ ,rn~lIn'J!l~mJn Hll~mnJl'lu~

rn~\lI11~m~y1~l'Illillll\ll{1u~thllcillllJlf'<1l1~fl,l1Jn~lllldJ pelvic organ prolapse• •

'i'lJA"1111'1lilrn1~ln~'1~11-1'Jw~cilJUHll~Mli~f111reduce pelvic organ nli'lJ Ul~l1rml

VlU1lpelvic organ prolapse ,i1-l'lJ\lI'IJ~lJlrn~'J!Nflll~stress urinary incontinence !l~• •

iJ~~U1-lrole 'JlJ~Yhl'lllfllrr\ll{11-1lm~iJrilJ1-IfmH,.1'1lJiJ~L~1-I11(lm~lI~tl\WQ111A'lb lOll'~1~

111lJ'hi iJ~ftmJll'l'lJ1l!llnml1l~ urodynamc finding ,m 1l.il~1-I'hJ~'I1utl1-lHviUlnlU~11-ln. .IL1-I~tl11Ir\ll11~VJm111Ih1-l';1~I:UIIUL!l~H\1~tl11lm1 \lI11~'1m lIlYiiJ!llfm1Jlfl'm~NmJn~l1~

ril:JuHll:;\1li~nl1Hl';llJ

Findings ~lnf111\l1n~m~y 1mllfnlf\ll{V1~l'I'lJ'1A'\11l111~l.lH'lJ'lJL'liUNfilJn1U1l

detmsor overctivity \~U good predictor 'J!l~f11~liillJpersistent of urgency and urge

incontinence Mli~f111Hl';llJresidual urine L~lJ~Ui'IlJ!~UMl1~f111Hl';llJHvilfwl'hu1mli~~~

~u1u I 1~!lU';l~I~UlflmlPl1J!l~ high residual urine Mill detrusor underactivity JUl!l~ ~~

lflt.11l f111'11f111m l~V1l~y11HllfflllVi{r)!l1-lf111Hl';l'IiJI'hU'lilulilU 11ll:Jlf111V1l~m11Jlfllll::

~lii\ll~Ul1li~nl1Hl';l'I1A'

8. 1111ml;)nNgh'l'Ull'lla\ll,'u~lhm1i1~1ll1f.h~fl Hysterectomy

rn1cilll1Jlllfll::H\lIt.ln~t.m!iifll~~ln f11~Hl1iflhJq~L;~n~l\.l(pelvic surgery) ~mJ

U!l(J1~Hrif11~\ll~lU'IJ!l~m~I,'n~iJlfllll~NmJn~ml~fmHl';llJ Abdominoperineal resection

Hll::nl1Hl';fl Radical hysterectomy

QUVi1ll1WIOflbladder dysfunction 't1i1~fl11f.h~fl'lfilfll'h~1H~~~

- 20-68% after Abdominoperineal resection

- 16-18'10 after Radical hysterectomy

- 20-25% after Anterior resection

- 10-20% after Proctocolectomy

uvi11-11J~~UUf111Hl';\lI'J~LlW if !1l'1Yl1J~Hl';fl11l'f11llJ~~JJm~1~mn~ U 1I1l::ijrn1r;l';llJ

111111Nerve-sparing radical hysterectomy mn~u ii~I~!l"hQu~rn1ru\;'~::ll\llll~ !JvN'hn•

fIllJL1Wl1J1lt.l1::mw10-20% 'JlJ~bladder dysfunction ljuL~mriJflml~ (penllanent

damage)

28

- Neurologic decentralization

- Tethering of nerves or encasement in scar

- Direct bladder or urethral trauma

- Bladder devascularization

bladder, detrusor underactivity, detrusor overactivity, bladder outlet obstruction, low

compliance, intrinsic sphincter deficiency 111lJ loss of urethral function (il1'Vl~ 15) ~~~

ij~lV~1'U1Mvltl1JnnVln~ bladder function ''U~''hvlocally advanced cervical carcimona

~1.\'i'1Jm~i'mn lVlvneoadjuvant chemotherapy and radical hysterectomy f-li1m~Vl~1~'l111

Q hl~l\flll'1'Vl{'YI1Jdetrusor overactivity (21%), mixed urinary incontinence (24%),

de novo stress incontinence (21%) I~UA'U

o'" T

!. Vol1000

Q50

Ovo!\000

p\les200

il1'Vl~ 15 Conventional urodynamic study shows detrusor underactivity (DU)

in a 45-year-old fcmale patient who underwent hystercctomy 4 years ago.

29

9. fm\il'4ilnHghl'll1ffHT\ili'lllfJlbu'IlK~nn1yWu Pelvic radiation

flufmn Cervical cancer l1~O Rectal cancer 1\i1Vf11'\llVlllY111~0i11IdlY11J1H1Vh1l1'

lOY]n14~un, n'll'!Ill'll111Uth~nl'~!I !llU4~~ !lg'!lu 11AYl~ii- Radiation proctitis, radiation cystitis (hemoragic cystitis)

- Stricture ureter, stricture urethra

- Vesicovaginal fistula, rectovaginaI fistula

- Contracted bladder

- Bladder dysfunction

Radiation effect ~ln\il~\jlJ1i1J\jiJfH1~001V,:;u\'ll\i1VIi111 nNll~m~wi10\il~1J1Iiv~

111l:;nNll~m~'Wlh:;lY1Y1.i',vnf111ftnl!1~1Iower tract function 1'Hl1fmfmn cervical

cancer .i'lVflU\llVlllY ~l'l1Ji llJ 1111lJH\iIUfl?l~l'l1J1JOV~l1\i1i'iodecreased bladder capacity

1111:;nflml~lJ~\j~O~ residual urine m1lJH\ilUn?l~ln\il~\Jci'ol illnmh6111 111f11'IllVlllY~l1~O

!l1i1ln\il1\J1l1l1viJ1111111~In\ilIl1J1J~,m 1111~,Hll'nRH' flum li1Y1l1Q1m1lf'lllY\iI{lYumtl 11Y

tm lW ilQVlI1l::1JOnll\J11mf111 f fll! 1~ !l1lJ1::l'flJ11'1 (n n1~ 16)

10. umqtJ (Conclusion)

flum li1Y1l~Qbl'lnrlll'fli1{ (urodynamic study) 1~\jIViv1!f1~o1jitnllj 1~lJm1IHf1fif.)J

~Ofll'lWilI1V1Wfl bfl f111~llllf fllJl 111l:;fl11?1\i1\i1llJf11HiuwtJbfl 'IJ!J1f111::flUri1V1Jl'flY11::

H\illlfl?lll~ ~1~nmllJlflfi\U~1 flilfii'iO flW~f11.h:: 1?1111l::f11WI'l1 il111fllVH1hvou 111l::10V'flu "

30

I

. OJ)! I-II!. Vol

_ 1000

-ll')-0

:'01:'~OO

r"'- Q '6:10_"I

Ii'.

L1. __ "1 i.---l-6..~_-'~'~

I

ilmn 16 Video-urodynamic study demonstrates very small bladder capacity, low

compliance, bilateral VUR grade 3, and acontractile bladder in a 65-year-

old female patient wbo underwent pelvic radiation for treating cervical

cancer 10 years ago.

31

l1u~allGHii~(References)

1. Schafer W, Abrams P, Liao L, Mattiasson A, Pesce F, Spangberg A, et al. Good

urodynamic practices: uroflowmetry, filling cystometry, and pressure-flow

studies. Neurourol Urodynam 2002;21 :261-74.

2. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al: The

standardisation of terminology oflower urinary tract function: report from the

standardisation sub-committee of the International Continence Society. Neurourol

Urodynam 2002;21: 167-78.

3. Neveus T, von Gontard A, Hoebeke P, Hjalmas K, Bauer S, Bower W, et al. The

standardization of terminology of lower urinary tract function in children and

aldolescents: report from the standardization committee of the International

Children's Continence Society (ICCS). Neurourol Urodynam 2007;26:90-102.

4. Blaivas J, Chanceller M, Weiss J, Verhaaren. Atlas ofurodynamics, 2nd ed.

Malden: Blackwell Publishing: 2007.

5. Wein AJ. Pathophysiology and classification of voiding dysfunction In: Wein AJ,

Kavoussi LR, Novick AC, editors. Campbell-Walsh Urology 9th ed. Philadelphia:

WB Saunders; 2007. p.l973-85

6. Peterson AC, Webster GD. Urdynamic and videourodynamic evaluation of voiding

dysfunction In: Wein AJ, Kavoussi LR, Novick AC, editors. Campbell-Walsh

Urology 9th ed. Philadelphia: WB Saunders; 2007. p.l986-2010

7. Tanako EA, Deng DY. Urodynamic studies In: Tanagho EA, McAninch JW.

Smith's General Urology 7th ed. New York: McGraw-Hill; 2008. pA55-n.

8. Anutrakulchai W, Mahawong P, Anutrakulchai S. Neurogenic lower urinary tract

dysfunction in pediatric lumbosacral myelomeningocele: urodynamic classification,

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