Avanceret udredning af urininkontinens

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Avanceret udredning af urininkontinens

• Mette Hornum Bing
• Lene Birgitte Paulsen
• Helle Christina Sørensen
• Helga M E Gimbel
• Susanne Greisen
• Gunnar Lose (tovholder)

Gynækologiske Guidelines Hindsgavl 2010
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• The bladder is an unreliable witness

Stanton 1984
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URODYNAMICS

• Studies provide an objective describtion
• of lower urinary tract function and
• dysfunction in terms of qualitative and
• quantitative variables

ICI 2005
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URODYNAMICS

• The study of the function and dysfunction of
  the urinary tract by any appropriate method

• non-invasive
• invasive

ICS 1988
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URODYNAMICS

• Urodynamic studies should be performed and
  reported in accordance with the standards (good
  urodynamic practices) of the ICS

ICS 2005
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FLOW og RESIDUALURIN (PVR)

• Simpel non-invasive undersøgelser
• (screening?)
• Flow og/eller PVR prædikterer voiding
• difficulties efter kirurgi (antimuscarin
• behandling?)
• Screening? (ønske objektiv diagnose)
• Flow PVR anbefales før intervention
• (specielt kirurgi) (C)

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CYSTOMETRI og TRYK-FLOW

• Invasiv kræver ekspertise
• SUI omkring 10 har DO
• OAB 50 DO
• MUI 30-50 har urodynamisk MUI
• Cystometri (B/C)
• er ikke nødvendig, hvis konservativ behandling
  påtænkes uanset
• dysfunktionens karakter (MUI, SUI eller UUI)
• hos kvinder med ren stressinkontinens, og normal
  uroflowmetri og
• residualurin er cystometri ikke nødvendig
  forud for operation
• Tryk-flow anvendes til at afgøre, om voiding
  difficulties
• skyldes a) obstruktion eller b) hypoaktiv
  detrusor

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URETHRAL TRYK

• Invasiv (ikke standardiseret)
• Alle parametre viser stor overlap mellem raske og
  syge
• Lave værdier (LPP lt 60 cm H2O og MUCP lt 20 cm
  H2O) er correleret til dårligere outcome af
  kirurgisk behandling
• Det kan ikke anbefales, at urethraltrykmåling
  anvendes som eneste urodynemiske test hos
  patienter med urininkontinens (B/C).

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BILLEDDIAGNOSTIK

• Der er ikke indikation for BD af øvre urinveje
  ved non-neurogen inkontinens
• PVR kan måles ved abdominal, vaginal eller
  transperineal UL
• Blærevægstykkelse gt5 mm er correleret til DO
• BD har endnu ikke klare indikationer ved
  udredning af non-neurogen urininkontinens bortset
  fra måling af PVR

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RISIKOFAKTORER VED MIDURETHRAL SLYNGER

• CURE RATE
• Alder (de novo urgency)
• BMI (gt 35)
• Tidligere operation for inkontinens
• MUI
• DO
• BN mobilitet
• ISD (LPP lt 60 cm H2O, MUCP lt 20 cm H2O) (TVT v.
  TO?)
• VOIDING DIFFICULTIES
• PVR
• Q-max (TO-TVT)

TVT v TO
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KONKLUSION (B/C)

• Screening? (ønske objektiv diagnose)
• Flow PVR anbefales før intervention (specielt
  kirurgi)
• Cystometri
• er ikke nødvendig, hvis konservativ behandling
  påtænkes uanset
• dysfunktionens karakter (MUI, SUI eller UUI)
• hos kvinder med ren stressinkontinens, og normal
  uroflowmetri og
• residualurin er cystometri ikke nødvendig forud
  for operation
• Tryk-flow anvendes til at afgøre, om voiding
  difficulties
• skyldes a) obstruktion eller b) hypoaktiv
  detrusor
• Det kan ikke anbefales, at urethraltrykmåling
  anvendes som eneste urodynemiske test hos
  patienter med urininkontinens.
• BD har endnu ikke klare indikationer ved
  udredning af non-neurogen urininkontinens bortset
  fra måling af PVR

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ANDET
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URODYNAMICS

• ideally should provide objective information
  useful for the clinician
• to identify or to rule out factors contributing
  to the incontinence and assess their relative
  importance
• to obtain information about other aspects of
  lower urinary tract dysfunction
• to predict the consequences of lower urinary
  tract dysfunction for the upper urinary tract
• to predict the outcome, including undesirable
  side effects, of a contemplated treatment
• to confirm the effects of intervention or
  understand the mode of action of a particular
  type of treatment, especially a new one
• to understand the reasons for failure of previous
  treatments for incontinence

ICS 2005
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Recommendations 1

• When invasive urodynamics is needed, a tailored
  evaluation of all factors is required
• symptoms, diary, non-invasive and invasive
  urodynamics
• filling and voiding
• bladder and urethra
• may need videourodynamics (imaging) or EMG
• Should be performed in specialized centers
• accredited urodynamics laboratory
• trained and certified staff
• results controlled for quality
• Proper training, accreditation, certification and
  quality-control programs required (Grade C)

ICI 05
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Recommendations 2

• Noninvasive urodynamic testing is recommended in
  every case (grade C)
• bladder diary, PVR, uroflow
• If any suggestion of complication
• Tailored, invasive urodynamics is required
• To show if situation truly is complicated
• To reveal all contributory factors
• To provide basis of rational treatment choice
• Only in simple situations
• Invasive urodynamics not required
• e.g. uncomplicated stress and urge incontinence

ICI 05