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Voiding dysfunction in female final presentation

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In absence of standardised criteria diagnosis of lower urinary tract dysfunction is difficult in women. Comprehensive urodynamics including pressure-flow study, urethral pressure profilometry, EMG as well as video coordination (or separately done MCUG) are often required. pelvic floor dysfunction (so called dysfunctional voiding), bladder neck obstruction and urethral stricture are differential diagnoses. initial treatment of dysfunctional voiding includes behavioural modification, pelvic floor relaxation exercises, medications, treatment of constipation. further treatment includes inj Botox into sphincter and sacral neuromodulation.

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Voiding dysfunction in female final presentation

  1. 1. VOIDING DYSFUNCTION IN WOMEN ​Dr Mayank Mohan Agarwal MBBS, MS, MRCS(Ed), ​DNB, MCh (PGIMER, Chandigarh) VMMF and IAUA Fellowships Uro-Oncology, Pelvic Floor Reconstruction (MSKCC, NY; UCLA, LA; WFUBMC, NC)​ Ex-Associate Professor of Urology (PGIMER, Chandigarh) Consultant and Head of Urology (Aster) Dr. Ramesh Cardiac and Multispecialty Hospitals Pvt. Ltd. Guntur (AP), India
  2. 2. INTRODUCTION • PHYSIOLOGY OF LOWER URINARY TRACT • THE DYSFUNCTIONAL VOIDING / BBD • WHAT TO LOOK FOR IN URODYNAMICS • MANAGEMENT OUTLINE • CONCLUSION
  3. 3. FILLING PHASE • INTRINSIC PROPERTIES – elastic / viscoelastic • AUTONOMIC NERVOUS CONTROL • PARASYMPATHETIC α1 • SYMPATHETIC β3 • SOMATIC NERVOUS CONTROL Aδ
  4. 4. FILLING PHASE • INTRINSIC PROPERTIES • AUTONOMIC NERVOUS CONTROL • PARASYMPATHETIC • SYMPATHETIC • SOMATIC NERVOUS CONTROL + SY + SO - PSY + - BLADDER ↔ URETHRA REFLEXES
  5. 5. VOIDING PHASE - SY - SO + PSY - + BLADDER ↔ URETHRA REFLEXES
  6. 6. Defecatory reflex
  7. 7. SAMPLING REFLEX
  8. 8. VOIDING DYSFUNCTION ANATOMIC FUNCTIONAL NEUROGENIC STRICTURE POST-SURGICAL PROLAPSE BLADDER NECK OBSTRUCTION PELVIC FLOOR DYSFUNCTION FOWLER’S SYNDROME Meier K, Padmanabhan P. Curr Opin Urol 2016; Kuo HC. Urology 2005. 1 23 4
  9. 9. KEY QUESTIONS TO BE ANSWERED • How is bladder storage function? • Is there an obstruction – how much? Where? • Is there an underactivity • Both?
  10. 10. Urodynamic perspective • Bladder diary • Free uroflowmetry ± EMG • Cystometry + pressure-flow study • Urethral pressure profilometry • Micturating cystourethrography • Video-urodynamics
  11. 11. Urodynamic perspective • Bladder diary • Free uroflowmetry ± EMG • Cystometry + pressure-flow study • Urethral pressure profilometry • Micturating cystourethrography • Video-urodynamics
  12. 12. Uroflowmetry ± EMG • Ideal location – within toilet • Ideal – “comfortably full bladder” Never ask to hold “too much” or “hurry up” • Always in “most preferred” voiding position • If straining pattern (+), ask to repeat without straining, if possible • Always check PVR by USG
  13. 13. Interpretation • Flow rates – Qmax • Qave – particularly in intermittent flow Agarwal et al. Neurourol & urodynam 2013, Agarwal MM. Manual of Urodynamics 2014 Qmax 11ml/s Qave 2.9 ml/s
  14. 14. Interpretation • Flow rates – Qmax • Qave – particularly in intermittent flow • Q α V2 • Voided volume • Post-void residue • Volume-normalized flow-rate index (VQI) ≡ BMI VQI = Q/√(VV+PVR) Agarwal et al. Neurourol & urodynam 2013
  15. 15. Flow-rates Indian reference values 0 5 10 15 20 25 30 35 adult male boy 5-10 boy 11-15 adult female girl 5-10 girl 11-15 Flow-rate comparison Qmax Qave VV 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 2.00 adult male boy 5-10 boy 11-15 adult female girl 5-10 girl 11-15 VQI comparison VQImax VQave Agarwal et al. Neurourol & urodynam 2013, Barapatre et al. Neurourol & urodynam 2009, Gupta et al. J urol 2013 MALES FEMALES MALES FEMALES
  16. 16. Uroflow with EMG
  17. 17. Urodynamic perspective • Bladder diary • Free uroflowmetry ± EMG • Cystometry + pressure-flow study • Urethral pressure profilometry • Micturating cystourethrography • Video-urodynamics
  18. 18. Multichannel urodynamics Cystometry / pressure-flow study / urethral pressure profilometry • Not a stand-alone investigation – clinical feedback essential • It is imperative to have bladder diary and results of free uroflowmetry with post-void residual urine, available • The interpretation best done in real-time “NURSE, RUSH THIS PATIENT TO THE MATERNITY WARD! SHE IS ABOUT TO DELIVER A BABY!”
  19. 19. Multichannel urodynamics Cystometry / pressure-flow study / urethral pressure profilometry • Not a stand-alone investigation – clinical feedback essential • It is imperative to have bladder diary and results of free uroflowmetry with post-void residual urine, available • The interpretation best done in real-time • Interpretation format – Filling phase Voiding phase Bladder Sensations Capacity Compliance DO, LPP Pdet – max, @Qmax, pattern Qmax AG DAMPF Urethra Length MUCP Pressure-gradient location of gradient EMG Guarding reflex cough reflex Relaxation pattern
  20. 20. LUTD : What are we looking for in filling phase + + - + - +/- +/- +/-
  21. 21. Filling phase • Bladder –  Over-activity
  22. 22. Filling phase • Bladder –  Over-activity  Compliance ∆V/∆P
  23. 23. Filling phase • Bladder –  Over-activity  Compliance • Urethra –  Resting profile  MUCP
  24. 24. Filling phase • Bladder –  Over-activity  Compliance • Urethra –  Resting profile  MUCP • EMG –  Guarding reflex
  25. 25. Filling phase • Bladder –  Over-activity  Compliance • Urethra –  Resting profile  MUCP • EMG –  Guarding reflex
  26. 26. Meier K, Padmanabhan P. Curr Opin Urol 2016
  27. 27. LUTD : What are we looking for in voiding phase • BN Dysfunction - - + - + + ++
  28. 28. BNO • Bladder –  Pdet  Qmax  PVR  Bell-shaped curve Pdetmax 72 PdetQmax 62 Qmax 8
  29. 29. BNO • Bladder –  Pdet  Qmax  PVR  Bell shaped curve • Urethra –  Pressure gradient  Starting point Jain et al. Urology 2014
  30. 30. • Bladder –  Pdet  Qmax  PVR • Urethra –  Pressure gradient  Starting point • EMG –  Relaxation Batavia et al. J Urol 2011
  31. 31. • Bladder –  Pdet  Qmax  PVR • Urethra –  Pressure gradient  Starting point • EMG –  Relaxation • Nomogram –  Blaivas Batavia et al. J Urol 2011
  32. 32. LUTD : What are we looking for in voiding phase • EUS Dysfunction - - + - + +/- + -
  33. 33. EUSD • Plateau pattern • Flow starts at Pdetmax • PdetQmax ≈ Pdetmax Agarwal et al. Ind J Urol 2016
  34. 34. EUSD • Plateau pattern • Flow starts at Pdetmax • PdetQmax ≈ Pdetmax Agarwal et al. Ind J Urol 2016
  35. 35. EUSD • Plateau pattern • Flow starts at Pdexmax • PdetQmax ≈ Pdetmax Agarwal et al. Ind J Urol 2016
  36. 36. EUSD • Plateau pattern • Flow starts at Pdexmax • PdetQmax ≈ Pdetmax Agarwal et al. Ind J Urol 2016
  37. 37. EUSD • Plateau pattern • Flow starts at Pdexmax • PdetQmax ≈ Pdetmax • Pura gradient at EUS Jain et al. Urology 2014
  38. 38. EUSD • Plateau pattern • Flow starts at Pdexmax • PdetQmax ≈ Pdetmax • Pura gradient at EUS Jain et al. Urology 2014
  39. 39. EUSD • Plateau pattern • Flow starts at Pdexmax • PdetQmax ≈ Pdetmax • Pura gradient at EUS Jain et al. Urology 2014
  40. 40. EUSD • Plateau pattern • Flow starts at Pdexmax • PdetQmax ≈ Pdetmax • Pura gradient at EUS Jain et al. Urology 2014
  41. 41. EUSD • Plateau pattern • Flow starts at Pdexmax • PdetQmax ≈ Pdetmax • Pura gradient at EUS • EMG – • Relaxation with intermittent spikes Batavia et al. J Urol 2011
  42. 42. EUSD • Plateau pattern • Flow starts at Pdexmax • PdetQmax ≈ Pdetmax • Pura gradient at EUS • EMG – • Non-Relaxation Batavia et al. J Urol 2011
  43. 43. EUSD • Plateau pattern • Flow starts at Pdexmax • PdetQmax ≈ Pdetmax • Pura gradient at EUS • EMG – • Increased activity Batavia et al. J Urol 2011
  44. 44. Urodynamic perspective • Bladder diary • Free uroflowmetry ± EMG • Cystometry + pressure-flow study • Urethral pressure profilometry • Micturating cystourethrography • Video-urodynamics
  45. 45. Video-urodynamics / MCUG • Anatomical correlation with functional findings • EUSD
  46. 46. Video-urodynamics / MCUG • Anatomical correlation with functional findings • Bladder neck
  47. 47. Video-urodynamics / MCUG • Anatomical correlation with functional findings • No BOO
  48. 48. Video-urodynamics / MCUG • Anatomical correlation with functional findings • Additional co-diagnosis Agarwal MM. Manual of Urodynamics 2014
  49. 49. Video-urodynamics / MCUG • Anatomical correlation with functional findings • Additional co-diagnosis • If done separately –  Cost effective  Catheter-less – less artefacts  ? Difficult co-interpretation Abrams P. Urodynamics 2006. Agarwal MM. Manual of Urodynamics 2014
  50. 50. Agarwal MM. Manual of Urodynamics 2014
  51. 51. CONSERVATIVE MEASURES STANDARD MEASURES – 1. Education is the key to success 2. Behavioral modification – • Fluid and diet • Timed voiding • Treatment of constipation SPECIFIC MEASURES – 1. Pelvic floor muscle exercises 2. Biofeedback 3. pharmacotherapy 4. Interventions • CIC • Botox • Neuromodulation Registration of symptoms and behaviors Positive reinforcement and support
  52. 52. Behavioral Modification • Eat and drink well – high fiber, adequate fluids • Avoid caffeinated beverages • Maintain hygiene • Void timely • Spend enough time Santos et al. Can Asso Urol J 2017
  53. 53. Behavioral Modification • Eat and drink well – high fiber, adequate fluids • Avoid caffeinated beverages • Maintain hygiene • Void timely (typically every 2 hours or depending on bladder diary) • Spend enough time • Good posture for toilet – “SQUATTING TYPE”
  54. 54. Behavioral Modification • Eat and drink well – high fiber, adequate fluids • Avoid caffeinated beverages • Maintain hygiene • Void timely (typically every 2 hours or depending on bladder diary) • Spend enough time • Good posture for toilet – “SQUATTING TYPE”
  55. 55. Behavioral Modification • Eat and drink well – high fiber, adequate fluids • Avoid caffeinated beverages • Maintain hygiene • Void timely (typically every 2 hours or depending on bladder diary) • Spend enough time • Good posture for toilet – “SQUATTING TYPE”
  56. 56. Behavioral Modification Treatment of constipation – • Manual evacuation • Polyethylene glycol 3350 1.5g/kg stat  0.6-1.0g/kg/d • Sodium picosulfate • Enema • Mineral oil
  57. 57. Physical therapy • Pelvic floor exercises • Relaxation • Urge inhibition
  58. 58. Physical therapy • Pelvic floor exercises • Relaxation • Urge inhibition • Step I – IDENTIFY THE MUSCLES TO EXERCISE • By verbal explanation – “like stop urine stream” “like stopping gas”
  59. 59. Physical therapy • Pelvic floor exercises • Relaxation • Urge inhibition • Step I – IDENTIFY THE MUSCLES TO EXERCISE • By physical examination – DRE PV perianal examination
  60. 60. Physical therapy • Pelvic floor exercises • Relaxation • Urge inhibition • Step I – IDENTIFY THE MUSCLES TO EXERCISE • By dedicated Biofeedback – if above two don’t work or while doing the UDS Biofeedback training Ed used to be an incurable optimist But now ne is cured
  61. 61. Biofeedback – done during uroflo with EMG
  62. 62. Biofeedback – done during UPP with EMG
  63. 63. Biofeedback – done during UPP with EMG
  64. 64. Biofeedback – done during UPP with EMG
  65. 65. Biofeedback – urge inhibition during UDS
  66. 66. STEP 2 - Exercise schedule • For pelvic floor relaxation – Squeeze 3-10 sec Relax 20-30 sec • For urge inhibition – Squeeze 5-10 times Relax for a sec • For strengthening – Squeeze 2-10 sec Relax for 1:1 45-60 SQUEEZES / D TO START WITH ± BIOFEEDBACK SESSIONS 1-2/WEEK FOR 45-60MIN 6-12 WEEKS
  67. 67. Outlet relaxation: PHARMACOTHERAPY Alpha blockers • Tizanidine • Baclofen
  68. 68. Outlet relaxation Alpha blockers • Terazosin – α1 (-) • Tamsulosin – α1a (-) Skeletal muscle relaxants • Baclofen – GABA-B (+) @ CNS • Tizanidine – α2(+) @ CNS • Effort should be made to diagnose level of non-relaxation • EUD non-relaxation more common than BN obstruction in women • α1 receptors possibly present in EUS too – combination may be acceptable option • High quality evidence is lacking – so treatment is empirical Athanasopoulos et al. IUJ 2009; Constantini et al. Urol int 2009; Cisternino et al. Urol Int 2006; Xu et al. BJUI 2007; Chen et al. J obs gyn res 2016;
  69. 69. Outlet relaxation: SURGERY BNI • BOTOX • SNM
  70. 70. Outlet relaxation: SURGERY • BNO: Bladder neck incision / resection • 5-7 or 10-2 or 3-6-9-12 O’clock • Excellent functional results • SUI • VVF • EUSD: Botox into sphincter • SNM: S3 • Pain • Reoperation • Loss of efficacy • High quality evidence is lacking Zhang et al. Urology 2014; Jin et al. Urology 2012 Phelan et al. J urol 2001; Kuo HC. Urology 2003; Kerrebroek et al. J urol 2007; Sutherland Neurourol Urodynam 2006
  71. 71. Conclusion • Urodynamics has a great role to play in diagnosis of voiding dysfunction. • ‘Reading between the lines’ beyond convention is required • Real-time interpretation is most preferred • Biofeedback can be taught during the urodynamic study as well • High quality evidence is lacking, therefore balance of art and science of treatment
  72. 72. -HAND HYGIENE- -PLACE HYGIENE- -LESS ANTIBIOTICS-
  73. 73. Compiled experience 2014-2017 • 33 adults with EUSD / double obstruction (median 46.6, IQR 39-53) • Duration of symptoms (48m, 15-96) • LUTS – all • Constipation – 9, fecal urgency – 1 • Pelvic &/or low back pain – 16 • Improvement with alpha blocker – 8 (4 mild) • Improvement with addition of tizanidine – 13 (3 mild)

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