婦女尿失禁

吳銘斌 醫師 (Ming-Ping Wu, M.D.,Ph.D.)

奇美醫學中心 婦產部婦女泌尿暨骨盆醫學科主任 台北醫學大學醫學院 婦產學科 副教授

成功大學醫學院臨床醫學研究所 博士

婦女尿失禁

(Female urinary incontinence)

婦女常見生殖泌尿道問題

• 泌尿道感染

• 生殖道感染

• 生殖道萎縮

• 月經週期異常

• 婦女泌尿疾病—尿失禁﹑頻尿﹑急尿

• 骨盆鬆弛—子宮脫垂﹑膀胱﹑直腸脫垂

男女大不同

男女大不同

男女大不同

Urogynecology

• Stress urinary incontinence

• Pelvic organ prolapse (POP)

Epidemiology:

Prevalence: Gender and Age

• Prevalence increases with age

Pooled Mean Prevalence of Urinary Incontinence*

Women ≥ 50 years 34%

Women < 50 years 25%

Men ≥ 50 years 22%

Men < 50 years 5%

*Thom D. J Am Geriatr Soc.

1998:473-480.

Bladder & Urethra

Normal Storage Voiding

Bladder Relaxed Contracted Urethra contracted relaxed

Stanton SL,Tanagho EA 1986 Springer-Verlag

Normal micturition cycle

尿道壓力

膀胱壓力

尿 失 禁 (urinary incontinence)

小便不自主的漏出 造成衛生及社交的困擾

International Continence Society, ICS

尿 失 禁 的 迷 思 ？

• 是老化的一部份？

• 是身為女人的一部份？

• 是生產後的正常現象？

• 醫師也幫不上忙？

生產:女人的戰場

尿失禁種類

• 應力性尿失禁

• 急迫性尿失禁

• 混合型尿失禁

• 溢出性尿失禁

• 其他類型: 脊髓損傷﹑瘺管等

為什麼我運動時 都會漏尿?

我咳嗽也會漏尿!

應 力 性 尿 失 禁

急迫性尿失禁 (urge incontinence)

應 力 性 尿 失 禁

(1) 正常 (2)尿失禁

急迫性尿失禁

混 合 性 尿 失 禁

溢 出 性 尿 失 禁

尿 失 禁 種 類

• 應力性尿失禁 40%

– 膀胱頸支撐組織變弱 – 尿道過動

– 尿道括約肌缺損

• 急迫性尿失禁 25%

– 逼尿肌不穩定

• 混合型尿失禁 25%

• 其他類型 10%

– 暫時性尿失禁

• 泌尿道感染

• 瞻妄

– 滿溢性尿失禁

• 脊髓損傷

– 瘻管

Bladder & Urethra

Normal Storage Voiding

Bladder Relaxed Contracted Urethra contracted relaxed

Abnormal Storage Voiding

Bladder Overactive Underactive Acontractile Urethra Incompetent

under stress

Functional or anatomic

obstruction Inappropriate

relaxaed

尿失禁﹑頻尿﹑急尿治療流程

• 婦女泌尿專科門診

• 內診檢查

– 咳嗽用力試驗

• 棉墊試驗

– 漏尿嚴重度

• 膀胱日誌

– 每週(日)喝水、解尿

、漏尿的自我紀錄

• (影像)尿動力學檢查

– 鑑別診斷尿失禁種類 – 鑑別診斷排尿異常

Cough stress test

Standing position

Squatting position

子宮脫垂嚴重度

www.moondragon.org/obgyn

第一度 第二度

第三度

子宮切除後之 陰道穹窿脫垂

尿動力學檢查 (Urodynamic study)

• 奇美B2婦女影像尿動力檢查室

Solar with video system

Rectum Bladder

30°

Bladder filled with 200 ml, I'm Straining

with Increased Force

up to Leak ! ^Pabd

Pves

Qura

60 80 100 120

Leak

尿動力學檢查

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf

0 100 200 300 400 500 600 ml

20 ml

Time 1 min/Div Speaking

FD

Cough

ND

UIDC

RH Cough

UU

SD

Cough

Leak

Urodynamic study: Cystometry

Nygaard & Heit

2004 Obstet Gynecol

Urodynamic stress incontinence

(USI)

Urodynamic stress incontinence (USI)

Detrusor overactivity (DO) w/wt incontinence

Nygaard & Heit 2004 Obstet Gynecol

Cystometry: DO without incontinence

Cystometry: DO with incontinence

Laborie Dorado™

Video-urodynamic study

選擇治療方式

•物理治療

•藥物治療

•手術治療

Nonsurgical Management of

Urinary Incontinence

Nonsurgical Management of UI:

Nonpharmacologic Treatments

• First-line therapy for both stress and urge incontinence

• Can reduce episodes of stress and/or urge incontinence by 50% to 80%^1,2,3,4

• Can lead to almost full continence for 25% to 50% of women treated^1,2,3

• Does not have to be aggressive or time- intensive to be effective³

1Fantl, JA, et al. JAMA. 1991:609-613.

2Burgio KL, et al. JAMA. 1998:1995-2000.

3Subak LL, et al. Obstet Gynecol. 2002:72-78.

4Burgio KL, et al. Obstet Gynecol. 2003:940-947.

Nonsurgical Management of UI:

Lifestyle Modifications

• Increase or decrease in fluid intake

• Reduction of dietary irritants

• Increase in dietary fiber

• Weight reduction

Nonsurgical Management of UI:

Behavioral Therapy行為治療

Bladder Training/ Scheduled Voiding

• Goal: Increase functional capacity of bladder

• Methods

– Deferred voiding (most commonly used method)

– Desensitization training – Timed voiding

Nonsurgical Management of UI:

Vaginal Cones

• 2002 Cochrane review^*

– Better than no active treatment for stress incontinence – As effective as PFMT and pelvic floor stimulation

*Herbison P, et al. The Cochrane Database of Syst Rev. 2002:CD002114.

(Colgate Medical, Berkshire)

物理治療

• 骨盆底運動(凱格爾運動)

• 生理回饋治療

• 電刺激療法

• 體外磁波治療

骨盆底肌

Nonsurgical Management of UI:

Physical Therapy:

Pelvic Floor Muscle Training (PFMT)

• Teaches women to identify pelvic floor muscles and to control their contraction

• Helps with all types of urinary incontinence, but especially with stress incontinence

• Rates of successful outcomes: 36% to 71%*

* Dannecker C, et al. Arch Gynecol Obstet. 2005:93-97.

Nonsurgical Management of UI:

Physical Therapy

Pelvic Floor Muscle Training (PFMT)

• Typical prescribed protocol

– 2 to 5 times per day

– 10 to 15 sets of contraction cycles

• Length of contractions: from as long as

possible, gradually increasing to 10 seconds

• Process takes at least 4 to 6 weeks and sometimes as long as 6 months

凱格爾運動

生理回饋治療

Demo

Case- pre

Case- post

Nonsurgical Management of UI:

Pelvic Floor Stimulation

• Electrical or magnetic stimulation

• Found to improve symptoms in 60%-90% of patients, with a 10%-30% cure rate¹

• Other studies: No more effective than PFMT alone^2,3

1Iselin CE, Webster GD. Urol Clin North Am. 1998:625-645.

2Goode PS, et al. JAMA. 2003:345-352.

3Spruijt J, et al. Acta Obstet Gynecol Scand. 2003:1043-1048.

Extracorporeal Magnetic

Innervation (ExMI)

藥物治療

• 年紀大或較輕度應力性尿失禁

• 膀胱過動症 (頻尿﹑急尿﹑急迫性尿 失禁)

• 嚴重頻尿﹑膀胱容積縮小

• 混合型尿失禁

• 無法開刀處理的尿失禁患者

Peripheral Action of neurotransmitters in the micturition cycle

藥物治療

Peripheral Action of neurotransmitters in the micturition cycle

The storage phase is mediated peripherally by Ach and NA

The voiding phase is peripherally mediated primarily by ACh

藥物治療

Nonsurgical Management of UI:

Alpha-adrenergic Receptor Agonists

• Ephedrine and pseudoephedrine

• Used off-label to treat mild stress incontinence

• Role in treatment of urinary incontinence not yet established

Nonsurgical Management of UI:

Tricyclic Antidepressants (TCAs)

• Imipramine only agent in this class widely studied

• Used when more effective medications have failed

• Serious side effects possible

手術治療

• 傳統膀胱頸懸吊手術

– Burch colposuspension – Pubo-vaginal sling

• 中段尿道懸吊手術(MUS)

(無張力陰道吊帶TVTs)

– 第一代 TVT, SPARC手術

– 第二代 TVT-O Monarc手術

– 第三代 TVT-Secure, MiniArc迷你手術

尿道

膀胱

The trend of different surgical

0 200 400 600 800 1000 1200

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 year n

RPU 59.5 Sling 59.4 TVTs 59.79 Kelly 59.3 Needle 59.6 59.71

Injection 59.72 RPU

Sling MUS Kelly Needle LS

Injection

台灣地區近十年來尿失禁手術改變驅勢

Wu MP, Tang CH, et. al 2008 Int Urogyn J

手術理論基礎 (Ulmsten Integral Theory)

PUL: pubo-urethral lig.

平 時 用力時

第一代: 經恥骨後系統

TVT vs TVT-O

Outside-in Delorme

•

Inside-out de Leval

•de Leval et al. 2003 Eur Urol

•Bonnet et al. 2005 J Urol

•Waltregny et al. 2005 J Urol

•Delorme E. Prog 2001 Urol

•Delmas V et al. 2003 Eur Urol

第二代: 經閉孔膜系統

第三代: 單一傷口(無出口)系統

第三代 TVT-Secure, MiniArc迷你手術

Kelly plication

Tradition bladder-neck sling

1st generation: Supra-pubic TVT, SPARC, IVS

2nd generation: Trans-obturator TVT-O, Monarc

The evolution of midurethral sling (MUS)

3rd generation: Single-incision TVT-secure, MiniArc

TVT: tension-free vaginal tape TVT-O: tension-free vaginal tape -obturator

SPARC: suprapubic arc

Endoscopic bladder neck suspension (EBNS)

你(妳)怎麼念呢?

膀胱過動症

頻尿

膀胱過動症

急尿

急迫性尿失禁

?

??

頻尿 (frequency) 與夜尿 (nocturia)

白天小便次數多(等)於八次自覺增加 每晚起床小便超過(等於)二次一次

急 尿 ^(urgency)

急迫性尿失禁 (urge incontinence)

1. The role of core symptom urgency in OAB ? 2. Do we need urodynamics for OAB ?

3. The patho-physiology and current medicationof OAB?

4. Pelvic organ prolapse (POP) and OAB?

– Can prolapse repair improve OAB?

Problems on current overactive

bladder (OAB) symptom syndrome

82

OAB Definition in 2002

• In 2002, ICS : Overactive bladder (OAB) “symptom syndrome“ suggestive of lower

urinary tract dysfunction.”

• Definition :

“Urgency, with or without urge incontinence, usually with

frequency and nocturia, if there is no proven infection or other obvious pathology.”

• Synonyms :

Urge syndrome

Urgency-frequency syndrome

83

3 distinctive OAB subtypes : 1. OAB dry

2. OAB wet

3. OAB with voiding difficulty

Hung MJ: 2006 J Urol 176:636-40

Core symptom

84

Hung MJ J Urol 2006;176:636-40

「膀胱過動症」常有的困擾

• 找廁所

• 不敢喝水

• 避免外出

• 剪少社交活動

• 擔心衛生及陰部異味

• 使用衛生綿或護墊

• 避免性生活

Hung MJ J Urol 2006;176:636-40

Impact on female adaptation by

OAB subtypes

87

The urgency of the problem and

the problem of urgency in the overactive bladder

• The relationship between the different symptoms of OAB Chapple BJU international,2005

The urgency of the problem and the problem of urgency in the overactive bladder

Urge

Urgency

• Desire to void

• Normal sensation

• physiology

• The complaint of a sudden compelling desire to pass

urine, which is difficult to defer (for the fear of leakage)

• Abnormal sensation

• pathology

Chapple CR 2005 BJU Int,

89

Practical Mandarin Terminology for Lower Urinary Tract Symptoms in Taiwan

Urgency

尿急(急尿) a)突然有強烈的排尿慾望，而且忍不住的感覺 b)突然有強烈的尿意，且無法憋尿

Urge urinary incontinence

尿急性尿失禁 a) 尿急憋不住伴隨不自主的漏尿 b) 因尿急憋不住而引發的漏尿

Chen et al. 2009 Incont Pelvic Floor Dysfunct

90

During normal cycle, desire to void (urge) is intermittent and increase with bladder volume.

During an urgency episode, the

desire to void

increases abruptly, resulting in a void, shortening the

intervoid interval, reducing the

volume voided

Chapple et al. BJU Int 2005

91

Refractory period: interval between voiding and the next urgency episode, can be measured and may be affected by therapy.

Warning time: can also be measured as the time from the onset of urgency to voiding

Chapple et al. BJU Int 2005

92

OAB Definition in 2010

• OAB:

Urgency, with or without urgency incontinence, usually with increased frequency and nocturia

• Urge syndrome urgency syndrome

• Frequency: daytime frequency

93

Lack of symmetry in both the term and definition between „Daytime frequency‟ and „night-time

frequency‟.

International Journal of Urology 2008,15;35-43

Urgency Incontinence Involuntary leakage preceded

by urgency Frequency

• Daytime frequency: complaint by the patient who considers that they void too often by day

• Nocturia (urination at night): complaint that the

patient has to wake up at night one or more times to void

OAB

OAB Symptoms

Urgency (core symptom)

• Sudden, compelling desire to pass urine that is difficult to defer

2. Do we need urodynamics for

OAB symptoms

Urodynamics in OAB

The need of urodynamics in OAB

• A total of 4,500 women 22-73 years of age

• 843 women (18.7%) OAB.

– 457 women (54.2%) urodynamically proven detrusor instability

– 386 women (45.8%) a stable urodynamic trace.

– 68 (8.1%) postvoid residual greater than 100 mL.

• 1,641/ 4,500 (36.5%) detrusor instability

– Only 27.5% (457 of 1,641) had OAB symptoms.

Digesu GA 2003 Neurourol Urodyn

Digesu GA 2003 Neurourol Urodyn

Autonomic Efferent Innervation Contributing to Bladder Contraction and Urine Storage

Ouslander JG 2004 NEJM

Antimuscarinic mechamism of action

– Detrusor muscle

→inhibit Ach binding to M receptor → stablize det muscle

→ ↑ bladder capacity

– Sensory receptors in uro/suburothelium → ↓ afferent nerve activity (Aδ-fiber and C- fiber )

– Significant reductions in urinary frequency, urgency and UUI episodes

Muscarinic Receptor Distribution

Bladder (detrusor)

Salivary glands Dry mouth

Colon Constipation

Heart

Stomach and

esophagus Dyspepsia

Iris/ciliary body Lacrimal gland

Blurred vision Dry eyes

Tachycardia

•Dizziness

•Somnolence

•Cognitive impairment, especially memory

CNS

 Narrow angle glaucoma

Contraindication for all antimuscarinics

Affinity for muscarinic receptor subtypes

Physiologic Effect Clinical Impact M₁ The receptor may play an important role in

cognition

↓ M₁ :↓cognitive adverse effects

M₂ ^•80 % (detrusor muscle) : M₂

•detrusor smooth muscle contraction (indirectly):

↓muscle relaxation of β- adrenoceptors

↓ M₂ :↓ cardiac adverse effects

M₃ ^•20% (detrusor muscle): M₃

•the main receptor subtype responsible for normal micturition contraction

Overly aggressive M₃blockade

→ constipation

M₄ M₅

Not present in the bladder in significant numbers

Unknown

Level Grade Antimuscarinics

Tolterodine 1 A (highly recommended)

Trospium 1 A (highly recommended)

Darifenacin 1 A (highly recommended)

Solifenacin 1 A (highly recommended)

Propantheline 2 B (Recommended)

Atropine, hyoscyamine 3 C (optional) Mixed Action Drugs

Oxybutynin (muscle relaxant effect)

1 A (highly recommended)

Propiverine (CC blocker) 1 A (highly recommended)

Dicyclomine 3 C (Optional)

Flavoxate 2 D ( possible)

Oxybutynin (Ditropan)

• 3 formulations: IR, ER, transdermal patch

• Well documented efficacy

• Active metabolite, N-desmethyl oxybutynin:

higher affinity for M1/M3 receptor over M2

• Relative non-selectiviy for bladder

• Common AEs: dry mouth, constipation, dyspepsia

• Poor long-term tolerability

Oxybutynin topical gel

• FDA approval in Jan 2009

• once-daily to abdomen, thigh, shoulder, or upper arm

• Evolution of transdermal gel may allow greater tolerability

• Improve compliance compared with previously available OXY formulations.

Tolterodine (Detrusitol)

• FDA approval for tx of OAB in 1998

• Two formulations: IR(2mg,bid) and ER(4mg,qd)

• Selectivity for bladder M receptor over salivary glands

• tolterodine ER: more effective and better tolerability

Nonsurgical Management of UI:

Tolterodine

• Available in immediate- and extended-release forms

• In meta-analysis* comparing short-acting forms of tolterodine and oxybutynin, tolterodine was associated with

– More incontinent episodes per 24 hours – But much better patient toleration

• long-acting oral tolterodine and long-acting oral oxybutynin showed similar results.^**

*Harvey MA, et al. Am J Obstet Gynecol. 2001:56-61.

**Diokno AC, et al. Mayo Clin Proc. 2003:687-695

Nonsurgical Management of UI:

Trospium

•  frequency of voids and episodes of urge incontinence

•  void volume

• Incidence of dry mouth in randomized placebo-controlled trial of solifenacin succinate

(1,059 adults)*:

– 7.7% for 5 mg group – 23% for 10 mg group – 2.3% for placebo group

Cardozo L, et al. J Urol. 2004:1919- 1924.

Solifenacin (Vesicare)

• Launched in Europe in 2004

• Competitive , selective M1 and M3 receptor antagonist

• Two formulations: 5 mg, 10 mg

• Higher potency against M3 receptor in SM than salivary gland

• Selectivity for bladder over salivary gland was greater than tolterodine, oxybutynin, darifenacin or atropine

A Comparison of the Efficacy and Tolerability of Solifenacin (5, 10 mg) Tolterodine (4mg) as an Acitve comparator in a Randomised (STAR) Trial:

at Treating Overactive Bladder Syndrome

Screening Baseline reading

Option to request increase dose ASSESSMENT

Week -2 Week 0 Baseline

Week 4 Week 8 Week 12

PRI Treatment

Placebo

Solifenacin 5mg

Tolterodine ER

Solifenacin 5mg + 5mg Solifenacin 5mg

Tolterodine ER + Placebo Tolterodine ER

Chapple CR et al, (2005): Eur Urol,48;3 :464- 470

Results of the STARTrial

Chapple CR et al, Eur Urol,48;3(2005):464-470

Treatment Outcomes in the STAR Study: A Subanalysis of

Solifenacin 5 mg and Tolterodine ER 4 mg

Chapple CR Eur Urol 2007; 52:1195- 1203

Hormone

Level of evidence Grade of

recommendation

Estrogen 2 C

Desmopressin * 1 A

*Nocturia

Nonsurgical Management of UI:

Hormone Therapy (HT)

• Used off-label for treatment of stress incontinence

• Meta-analyses: No objective improvement in urine loss^1,2

• WHI and HERS data^4,5

– Both estrogen and estrogen/progesterone HT associated with increased risk of urinary incontinence

– Risk greatest for stress incontinence

– HT users more likely to limit daily activities

• HT now considered a risk factor for urinary incontinence

1Fantl JA, et al. Obstet Gynecol.

1994:12-18.

2Al-Badr A, et al. J Obstet Gynaecol Can. 2003:567-574.

3Hendrix SL, et al. JAMA. 2005:935-948.

4Steinauer JE, et al. Obstet Gynecol.

2005:940-945.

Estrogen

• Estrogen therapy may be effective in

alleviating the symptoms suggestive of OAB.

• Local administration may be the most beneficial route of administration.

Cardozo L et al. Acta Obstet Gynecol Scand 2004;83:892-97

• Alleviating symptoms of urgency, frequency and UUI may be a manifestation of urogenital atrophy in older postmenopausal women

rather than a direct effect on LUT

Robinson D et al. Urology 2003;62:45-51

A Randomized, Comparative Study of the Effects of Oral and Topical Estrogen Therapy on the Lower Urinary Tract

of Hysterectomized Postmenopausal Women

- Long, Fertil Steril 2006

Pharmacotherapy for overactive bladder.

Igawa 2000 Urol 55 (supp 5A): 47- 49

Patil A & Duckett 2010 Curr Opin Obs Gyn

Toxins

Level of evidence Grade of

recommendation Botulinum toxin

(neurogenic)

2 A

Botulinum toxin (idiopathic)

3 B

Capsaicin (neurogenic)

2 C

Resiniferatoxin (idiopathic)

2 C

Botulinum toxin

• Neurotoxin produced by G(+) anaerobic organism Clostridium botulinum.

• Inhibit release of acetylcholine at neuromuscular junction

=> causes muscle relaxations =>chemodenervation

• Not yet licensed for use in bladder symptoms.

• 2^nd line treatment in pts refractory to conventional antimuscarinic therapy

Mechanism of action of botulinum toxin

• Normal release of Ach at the neuromuscular junction

Ho MH et al 2005 Curr Opin Obs Gyn SNARE: N-ethylmaleimide sensitive factor attachement receptor

Mechanism of action of botulinum toxin

• Exposure to Botulinum Toxin

Ho MH et al 2005 Curr Opin Obs Gyn

BTX-A intravesical injections

• Detrusor injection of 200 U Botox (Allergan,

Irvine, USA): 73% success rate in 30 idiopathic detrusor overactivity (IDO) patients (Kuo HC 2004 Urol)

• Suburothelial injections of Botox at a dose of 200 U revealed therapeutic results (85%

success rate) as good as those with 300 U ^{(Kuo HC}

2005 Urol)

4. OAB and pelvic organ prolapse (POP)

• What is the possible pathophysiology of OAB in POP?

• Do OAB symptoms and DO change after conservative or surgical treatment of POP?

當「膀胱過動症」合併骨盆鬆弛時 ，骨 盆重建手術可同時改善「膀胱過動症」

症狀

子宮脫垂嚴重度

www.moondragon.org/obgyn

第一度 第二度

第三度

子宮切除後之 陰道穹窿脫垂

OAB and pelvic organ prolapse (POP)

• Community- and hospital-based studies showed that the prevalence of OAB symptoms was greater in patients with POP than without POP.

• No evidence was found for a relationship between the compartment or stage of the prolapse and the presence of OAB symptoms.

• All treatments for POP (surgery, pessaries) resulted in an improvement in OAB symptoms.

De Boer 2010 Neurourol Urodyn

「膀胱過動症」與骨盆鬆弛

•有骨盆鬆弛者比無骨盆鬆弛者「膀胱過動症」出 現比率為2.1-5.8倍

De Boer 2010 Neurourol Urodyn

「膀胱過動症」藥物治療與骨盆鬆弛

• 有骨盆鬆弛者比無骨盆鬆弛者「膀胱過動症」藥物治癒率 比率為較差(2. 55 比7.09倍)

De Boer 2010 Neurourol Urodyn

骨盆重建手術

(pelvic reconstructive surgery)

• 使骨盆腔內的臟器 回復到原來的位置

• 骨盆重整手術

經陰道進行手術

使用人工網膜支撐骨盆肌肉韌帶

• 骨盆重整手術合併尿失禁手術

Cardinal ligament

arcus tendineus fasciae pelvis Rectovaginal fascia

Pubocervical ligaments

Pelvic suppport structures

6 Ligaments, 2 Fascia, 1 Ring

TeLinde’s Operative Gynecology

Pericervical ring

Tension-free vaginal mesh

(TVM)

無張力人工網膜植入術

Tension-free Vaginal Mesh (TVM)

Monarc or TVT-O or Miniarc

Prolift (ant) or Perigee

Prolift (post) or Apogee

A B

Preserved uterus Hysterectomized

Gynecare, J&J AMS; Tyco

OP record for TVM +/- TVT-O

手術原則趨勢

•傷口小

•手術時間短

•恢復快

•術後疼痛減輕

•術後導尿管

•美觀

尿失禁&骨盆鬆弛 治療無壓力

Prevalence of OAB Symptoms

Before and During Treatment With Pessary

• 使用子宮托後改善「膀胱過動症」治癒率 比使用前(1.5-2.6倍)

De Boer 2010 Neurourol Urodyn

「膀胱過動症」與骨盆重建手術

• 骨盆重建手術後改善「膀胱過動症」治癒率比術 前(1.0-6.5倍)

夢想不該隨著年紀愈大而縮水

2009.12. 15 醫樂室內樂及眷屬舞群

2009奇美門診區整修完工音樂會

1. What relationship between the group 1 and group 2

questions in the following questionnaire? (A) irrelevant;

(B) group 1 voiding, group 2 storage; (C) group 1 storage, group 2 voiding, (D) quality of life.

Evaluation

2. In a patient with a history consistent with an overactive bladder (OAB),

which of the following study is the most useful?

(A) Valsalva leak point pressure,

(B) frequency/volume bladder chart over 48 hours,

(C) pelvic ultrasound,

(D) pressure-flow study.

Medication

3. The most common side effect of oxybutynin which lead poor medical compliance is:

(A) blurred vision, (B) dry mouth,

(C) drowsiness, (D) nausea,

(E) constipation.

(Ref Clin Obs Gyn 2004).

Conservative treatment

4. The most effective non-surgical treatment of stress urinary

incontinence is:

(A) pelvic muscle training, (B) vaginal weights,

(C) electronic stimulation, (D) hypnosis,

(E) bladder training.

(Ref Clin Obs Gyn 2004).

Urodynamics

5. What is your diagnosis for the

urodynamic study (arrow indicates urine leakage)?

(A) urodynamic stress incontinence,

(B) detrusor overactivity incontinence, (C) low compliance bladder,

(D) sensory urgency,

(E) detrusor sphincter dyssynergia (From: Nygaard & Heit 2004 Obstet

Gynecol).

Surgery

6. Which treatment option for stress

urinary incontinence consistently results in significant improvement?

A. Anterior colporrhaphy;

B. Kelly plication ;

C. Retropubic urethropexy; e.g. MMK, Burch

D. Needle urethropexy.

Nonsurgical Management of UI:

Managing Anticholinergic Adverse Events

• Dry mouth

– Use regular or sugar-free candy, lozenges, gum or mouthwash.

– Increase fluid intake (six 8-oz glasses daily).

• Constipation

– Increase fluid intake.

– Increase intake of fluids (e.g., prune or apple juice) that stimulate bowel movements.

– Increase dietary fiber.

– Take psyllium (1 tsp before breakfast and dinner).

– Take docusate sodium (1 tablet 1-3 times/day).

Adapted from: Staskin DR, MacDiarmid SA. Am J Med. 2006:24S-28S.