Assessment and investigation of physical examination in female stress urinary incontinence and pelvic organ prolapse
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1 Assessment and investigation of physical examination in female stress urinary incontinence and pelvic organ prolapse 吳銘斌 1,2,3 奇美醫院婦產部 1 台北醫學大學醫學院婦產學科助理教授 2 成功大學醫學院臨床醫學所博士候選人 3
2 Bladder & Urethra function during storage and voiding Normal Storage Voiding Bladder Relaxed Contracted Urethra Contracted Relaxed Abnormal Storage Voiding Bladder Overactive Underactive Acontractile Urethra Incompetent under stress Inappropriate relaxed Functional or anatomic obstruction
3 Normal Storage & Voiding Function Unique function of bladder & urethra Autonomic & somatic control. Distention & capacitance role for storage & emptying Reflexic & conscious emptying. Learned behaviors to coordinate voiding cycle & response to stimuli Requires physical integrity of supporting structures
4 Female Continence Mechanism Internal sphincter External sphincter Mucosal coaptation Endopelvic fascia Muscles of pelvic floor Bony structure support
5 Pelvic bony structure
6 Levator ani m.
7 ATFP
8 Pubo-cervical fascia
9 Normal vaginal axis in nulli-parous woman in the standing position Walters MD, Karram MM 1999 Mosby
10 Level 1 (apical suspension) & Level 2 (lateral attachment) Paracolpium Cardinal-US complex ATFP DeLancey JO 1992 Am J Obstet Gynecol
11 Assessment in female SUI/ POP History questionnaire Bladder diary Physical examination PV & NE Lab Urinalysis Pad test Ultrasound Urodynamic study (UDS)
12 The standardization of terminology in lower urinary tract function 1. Lower urinary tract symptoms (LUTS) 2. Signs suggestive of lower urinary tract dysfunction (LUTD) 3. Urodynamic observations and conditions 4. Conditions 5. Treatment ICS 2002 Am J Obstet Gynecol; Neurourol Urodyn
13 1. Lower urinary tract symptoms (LUTS) 1.1 Storage symptoms 1.2 Voiding symptoms 1.3 Post micturition symptoms ICS 2002 Am J Obstet Gynecol; Neurourol Urodyn
14 1. Lower urinary tract symptoms (LUTS) Post micturition symptoms Chapple CR 2005 Nat Clin Practice Urol
15 1.1 Storage symptoms (i) Increased daytime frequency pollakisuria used in many countries. Nocturia Urgency Urinary incontinence any involuntary leakage of urine. (NEW) Stress urinary incontinence on effort or exertion, or on sneezing or coughing. (CHANGED) Urge urinary incontinence accompanied by or immediately preceded by urgency. (CHANGED) Mixed urinary incontinence ICS 2002 Am J Obstet Gynecol; Neurourol Urodyn
16 1.1 Storage symptoms (ii) Enuresis any involuntary loss of urine. (ORIGINAL) Nocturnal enuresis loss of urine occurring during sleep. (NEW) Continuous urinary incontinence Other types of urinary incontinence situational, e.g. during sexual intercourse, or giggle incontinence. Bladder sensation Normal Increased, Reduced Absent, Non-specific
17 1. Lower urinary tract symptoms (LUTS) 1.4 Symptoms Associated with Sexual Intercourse Dypareunia, vaginal dryness, and incontinence during penetration, during intercourse, or at orgasm. 1.5 Symptoms Associated with Pelvic Organ Prolapse The feeling of a lump ( something coming down ), low backache, heaviness, dragging sensation, the need to digitally replace the prolapse in order to defaecate or micturate.
18 DIAPPERS Delirium/ confusional status Infectious-urinary (symptomatic) Atrophic urethritis/ vaginitis Pharmaceuticals Psychologic, esp. depression Endocrine (hypercalcemia, hyperglycemia) Restricted mobility Stool impaction
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21 Incontinence Impact Questionnaire Short Form IIQ-7 Benson JT 2000 McGraw-Hill Co.
22 Urogenital Distress InventoryShort Form UDI-6 Benson JT 2000 McGraw-Hill Co.
23 SEAPI-QMM S: Stress-related leak E: Emptying ability A: Anatomy (female) P: Protection I: Inhibition Q: Quality of life M: Mobility M: Mental status
24 S ( 應力相關的漏尿 ) 0: 無漏尿 1: 費力的活動時會漏尿 2: 中等活動時會漏尿 3: 輕微活動時會漏尿 E ( 排尿能力 ) 0: 無阻塞性症狀 1: 輕微症狀 2: 明顯症狀 3: 以滴尿方式解尿尿液滯留 A ( 解剖位置 ) 0: 用力時無下降 1: 下降, 未到陰道口 2: 用力時突出陰道口 3: 未用力時即突出陰道口 P ( 護墊須要性 ) 0: 不須要 1: 只有某些場合使用 2: 偶爾漏尿時才用 3: 常常發生漏尿或持續漏尿而須連續使用 I ( 抑尿能力 ) 0: 沒有急迫性尿失禁 1: 很少急迫性尿失禁 2: 約一週一次急迫性尿失禁 3: 一天最少一次急迫尿失禁
25 S ( 應力相關的漏尿 ) 怒責動作 ( Valsava effort) 及咳嗽 0: 無漏尿 1: 大於 80cmH2O 才漏尿 2: 30-80cmH2O 漏尿 3: 小於 30cmH2O 漏尿 E ( 排尿能力 ) 解尿後餘尿須重覆測 0: 0-60ml 1: ml 2: ml 3: >20ml 或無法解尿 A ( 解剖位置 ) 膀胱 X 光攝看膀胱頸在怒責動作及咳嗽時與恥骨聯合的相關性 0: 用力時在恥骨聯合上 1: 用力時在恥骨聯合下 2cm 以內 2: 用力時在恥骨聯合下 2cm 以上 3: 休息時在恥骨聯合下 2cm 以上 P ( 護墊須要性 ) 0: 不須要 1: 只有某些場合使用 2: 偶爾漏尿時才用 3: 常常發生漏尿或持續漏尿而須連續使用 I ( 抑尿能力 ) 膀胱容積壓力圖 0: 無壓力上升 1: >500ml 以上壓力上升 2: ml 壓力上升 3: <150ml 早發壓力上升
26 2. Signs suggestive of lower urinary tract dysfunction (LUTD)
27 2.1 Measuring the Frequency, Severity and Impact of Lower Urinary Tract Symptoms Micturition time chart only the times of micturitions, day and night, for at least 24 hours Frequency volume chart (FVC) the volumes voided as well as the time of each micturition, day and night, for at least 24 hours. Bladder diary the times of micturitions and voided volumes, incontinence episodes, pad usage fluid intake, the degree of urgency and the degree of incontinence.
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30 2.2 Physical examination Abdominal examination Distended bladder Abdominal palpation Suprapubic percussion Old incisions Distension Masses Flank tenderness
31 2.2 Physical examination Perineal/genital inspection Urinary incontinence (the sign) urine leakage seen during examination urethral or extraurethral. Stress urinary incontinence the observation of involuntary leakage from the urethra, synchronous with exertion/ effort, or sneezing or coughing. due to raised abdominal pressure. Extra-urethral incontinence Uncategorized incontinence
32 Cough stress test Standing position
33 Cough stress test Squatting position
34 Q-tip test Benson JT 2000 McGraw-Hill Co.
35 2.2 Physical examination Vaginal examination Pelvic organ prolapse Absence of prolapse: stage 0 support; prolapse from stage I to stage IV. Anterior vaginal wall prolapse Prolapse of the apical segment of the vagina descent of the vaginal cuff scar (after hysterectomy) or cervix Posterior vaginal wall prolapse
36 Vaginal specula
37 Pelvic organ prolapse (POP) Vaginal Profile (Grade 1-4) 1972 Baden & Walker (hymnal ring) Grading system (1st- 3rd degree) 1980 Beecham (introitus) Quantitative POP (Stage I-IV) 1996 ICS, AUCS, SGS Simplified POP 2006 IUGA
38 Pelvic organ prolapse- quantitation (POP-Q) Bump RC 1996 AJOG
39 Lankmarks in POP-Q
40 POP-Q Q complete eversion of vagina Bump RC 1996 AJOG Stage IV C Stage 0
41 POP-Q Q ant-,, post- support defect Bump RC 1996 AJOG Stage III Ba Stage III Bp
42 POP-Q Stage 0: No prolapse is demonstrated. Points Aa, Ap, Ba, and Bp are all at -3 cm and either point C or point D is within 2 cm of TVL. Stage I: The most distal portion of the prolapse is 1 cm above the level of the hymen (above -1). Stage II: The most distal portion of the prolapse is 1cm proximal to or distal to the hymen. Stage III: The most distal portion of the prolapse is 1 cm below the hymen but protrudes no further than 2 cm less than the total vaginal length. Stage IV: Complete eversion is present.
43 聖路易美國 台南台灣
44 Anterior compartment: Cystocele
45 Anterior vaginal wall prolapse Miklos JR 2002 Curr Opin Obstet Gynecol
46 Transvaginal mesh (TVM) technique
47 Prolapse of the apical segment of the vagina Miklos JR 2002 Curr Opin Obstet Gynecol
48 Enterocele: peritoneum in direct contact with vaginal epithelium with no intervening fascia Miklos JR 2002 Curr Opin Obstet Gynecol Benson JT 2000 McGraw-Hill Co.
49 Posterior vaginal wall prolapse Miklos JR 2002 Curr Opin Obstet Gynecol
50 Fig. Rectocele site-directed repair
51 Rectocele site-directed repair Distal U-shape defect Transverse defect
52 Rectocele Rectocele site-directed repair Hocky stick defect Double defect
53 Neurologic examination Mental status Sensory function Motor function Deep tendon reflexes Sacral reflexes Anal reflex Bulbo-cavernosus reflex
54 Sensory dermatone function Benson JT 2000 McGraw-Hill Co.
55 Motor function Benson JT 2000 McGraw-Hill Co.
56 Sacral reflex Anal reflex Bulbocarvernosus reflex Benson JT 2000 McGraw-Hill Co.
57 2.2 Physical examination Pelvic floor muscle function Qualitatively defined: strong, weak or absent Validated grading system (e.g. Oxford 1-5). by visual inspection, by palpation, EMG or perineometry Rectal examination Rule out fecal impaction
58 P.E.R.F.E.T. Power. Oxford scale 0: nil, 1: flicker; 2: weak; 3: moderate; 4: good; 5: strong Endurance. Repetitions. Fast. Every. Contraction. Timed.
59 2.3 Pad testing may be used to quantify the amount of urine lost during incontinence episodes, methods range from a short provocative test to a 24- hour pad test.
60 Walter MD Elsevier
61 Walter MD Elsevier
62 Urodynamics Life Tech Co.
63 Indications for multichannel subtracted cystometry Kohli N 1998 Clin Obstet Gynecol
64 Thank you for your attention! Tainan, Taiwan
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