Mr. GIT KAH ANN. Pakar Klinikal Urologi Hospital Kuala Lumpur.

Transcription

1 Mr. GIT KAH ANN Pakar Klinikal Urologi Hospital Kuala Lumpur 25 Jan 2007

2 HIGHLIGHTS Introduction ICS Definition Making a Diagnosis Voiding Chart Investigation Urodynamics Ancillary Investigations

3 INTRODUCTION 1 Overactive bladder overused word with many definition Original ICS definition OAB refers to the storage phase of the bladder and is diagnosed by urodynamics Overactivity caused by involuntary detrusor muscle contraction that occur while patient try to inhibit voiding

4 INTRODUCTION 2 OAB due to neurological disease hyper-reflexic reflexic OAB due to non-neurological neurological unstable However some OAB will not demonstrate itself in CMG & patient respond to treatment Insisting on a CMG before starting treatment hampers many patients to receiving treatment

5 ICS DEFINITION ICS Terminology Committee Report Urgency with or without urge incontinence usually with frequency and nocturia confirm no infection or other local pathology CMG not compulsory

6 ICS DEFINITION 2 ICS highlight 3 key points 1. Diagnosis of OAB does not rely on CMG. only on patients symptoms 2. Urgency is the fundamental symptom 3. OAB is a syndrome. several symptoms determining the severity and state of this condition

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8 HISTORY 1 Accurate and detail history Urgency Sudden compelling desire to void which is difficult to defer Frequency Voiding > 7 times during waking hours Nocturia One or more voids at night

9 Urge Incontinence Other LUTS Voiding difficulties Haematuria Dysuria Recurrent UTI Previous history Drug history HISTORY 2 Anticholinergic,, antidepressant, psychotropics.. Alpha blocker

10 HISTORY 3 Sexual and bowel dysfunction IBS Faecal incontinence POP Predisposing factors Dietary factor (eg( spicy food, caffeine) Fluid intake Psy & mental status (stress, personality) Comorbids (DM, DI) Previous pelvic surgery

11 QUANTIFY SEVERITY Incontinence Impact Questionnaire Investigate how incontinence affects daily living activities, physical activities and social interaction Bristol Female Lower Urinary Tract Symptoms (FLUTS) questionnaire 20 items Urgency, UUI, SUI, pads, frequency, nocturia & bothersomeness

12 EXAMINATION 1 Often neglected P/A pelvic mass, palpable bladder V/E POP, oestrogen status, infection, pelvic mass Pelvic floor Pelvic floor strength SUI

13 EXAMINATION 2 Neurological assessment (S2-S4) S4) Vulval & perianal sensation Bulbocavernosus & anal reflex Lower limb (motor, sensory & reflex) DRE

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15 VOIDING CHART 1 Most important but often neglected 2 to 7 days, 3 days most reliable Reproducible objective assessment Records Fluid intake time & volume of micturation Incontinence urgency

16 VOIDING CHART 2 Information obtained Bladder behaviour Severity of incontinence Suggest urinary disorder Reveal excessive fluid intake Baseline for treatment

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18 PAD TEST Simple test to confirm and quantify urinary leak & evaluate treatment 1 hour pad test Standard fluid intake & a set of activity hour pad test Patient performs daily routine Collect pads and weigh

19 URINALYSIS Bacteriuria, pyuria Urine C/S Haematuria suggest urinary tract pathology Urine cytology tumour,, CIS

20 UROFLOW & PVRU Assess voiding dysfunction (often coexist and symptoms mimic OAB) Simple test before CMG Voided volume BOO PVRU Chronic retention voiding dysfunction Side effect of treatment Select patient for treatment Assess on going treatment

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22 URODYNAMICS 1 Pobable diagnosis unclear Neuropathy suspected Treatment unsuccessful Not required in all OAB High prevalence of OAB Will delay treatment need referral Not always correlate Malone-Lee J, et al. Br J Urol 2003;92:415-7

23 URODYNAMICS 2 OAB is a sensory effect Not necessarily due to involuntary detrusor contraction during storage phase Because urgency is the key symptom CMG may be normal (Digesu( et al) 46% of 4500 women with OAB symptoms Digesu et al. Neurourol Urodyn 2003;22:105-8

24 URODYNAMICS CLASSIFICATION OAB symptoms not specific Pathological conditions have similar symptoms Classification may be useful as a guide for prognosis and therapy Flisser et al. J Urol 2003;169:529-34

25 TYPE 1 Flisser et al. J Urol 2003;169: Type 1 overactive bladder in 43-year year-old woman who complained of urgency, frequency and bladder pain, and voided more than 30 times in 24 hours. Urodynamic tracing shows small capacity, hypersensitive bladder with flat detrusor tracing and inability to initiate voluntary detrusor contraction (IDC( IDC). There were neither voluntary nor involuntary detrusor contractions.

26 TYPE 2 Flisser et al. J Urol 2003;169: Type 2 overactive bladder in 55-year year-old woman with urgency and frequency. Urodynamics reveals involuntary detrusor contractions, which patient perceived as urge to void. She was able to suppress this urge and contracted urinary ry sphincter to maintain continence. At study end she voided voluntarily.

27 TYPE 3 Flisser et al. J Urol 2003;169: Type 3 overactive bladder. Urodynamics demonstrates involuntary detrusor contraction (IDC) in 46-year year-old woman. Involuntary detrusor contraction was perceived as urge to void. She maintained continence temporarily by contracting sphincter but then voided uncontrollably.

28 TYPE 4 Flisser et al. J Urol 2003;169: Type 4 overactive bladder in 82-year year-old woman who underwent urodynamics due to urinary urgency, frequency and urge incontinence. Involuntary detrusor contraction occurred. Patient was unaware of it and voided uncontrollably, unable u to stop urinary stream.

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30 Ultrasound RADIOLOGY Bladder pathology (calculi, tumours,, FB) Mobility & opening of bladder neck Bladder wall Renal USG hydronephrosis Video urodynamics VUR, diverticula,, fistula

31 CYSTOSCOPY Exclude bladder pathology FB (sutures) & bladder calculi Bladder hydrodistention

32 NEUROPHYSIOLOGY EMG Nerve conduction Optional tests Future role with advancement of neuromodulation in refractory OAB Abrams P et al. Incontinence1999;157-95

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34 CONCLUSION OAB is common Good history with a voiding chart sufficient to diagnose OAB Need to exclude other pathology CMG is optional Unsure diagnosis Not responding to treatment

35 Sunset at Kota Kinabalu