Voiding dysfunction A Simple Approach Towards Understanding and Management - by Prof.Dr.Tarek Osman

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Detailed presentation about classification, evaluation and treatment of voiding dysfunctions by Prof.Dr.Tarek Osman

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Voiding dysfunction A Simple Approach Towards Understanding and Management - by Prof.Dr.Tarek Osman

  1. 1. Voiding DysfunctionVoiding Dysfunction A Simple ApproachA Simple Approach Towards UnderstandingTowards Understanding and Managementand Management Tarek Osman M.D.Tarek Osman M.D. Professor, UrologyProfessor, Urology Department,Department, Ain-ShamsAin-Shams UniversityUniversity Cairo, Egypt.Cairo, Egypt.
  2. 2. NeurophysiologyNeurophysiology
  3. 3. Pontine Micturition Center (Maestro) Lower UT (Bladder &Urethra) Higher Cortical centers (CC, Hypoth, Cerebellum) Pontine Voiding Center (M region) Pontine Storage Center (L region) Storage Reflex Voiding Reflex
  4. 4. Storage ReflexStorage Reflex  InputInput: Ascending Impulses: Ascending Impulses from the urothelium via Afrom the urothelium via A δδ fibers and C fibers infibers and C fibers in pelvic nerve & Descendingpelvic nerve & Descending impulses from higherimpulses from higher centerscenters  CenterCenter PMC –L regionPMC –L region  OutputOutput 1.1. Stimulation of SympatheticStimulation of Sympathetic outflow Toutflow T 1010-L-L11 Hypogastric nerveHypogastric nerve 2.2. Inhibition of the P.SympInhibition of the P.Symp outflow from Soutflow from S 2,3,42,3,4 (Pelvic(Pelvic nerve)nerve) 3.3. Stimulation of the outletStimulation of the outlet Center SCenter S 2,3,42,3,4 (Onuf n.)(Onuf n.) (Pudendal nerve)(Pudendal nerve) Symp T10-L1 P.Symp S2,3,4 (Interomed) Motor S2,3,4 (Onuf)
  5. 5. Voiding ReflexVoiding Reflex  InputInput:: Ascending ImpulsesAscending Impulses from the urothelium &from the urothelium & Descending impulses fromDescending impulses from higher centershigher centers  CenterCenter PMC –M regionPMC –M region  OutputOutput 1.1. Inhibition of SympatheticInhibition of Sympathetic outflow Toutflow T 1010-L-L11 HypogastricHypogastric nervenerve 2.2. Stimulation of the P.SympStimulation of the P.Symp outflow from Soutflow from S 2,3,42,3,4 (Pelvic(Pelvic nerve)nerve) 3.3. Switch off the outlet CenterSwitch off the outlet Center SS 2,3,42,3,4 (Onuf n.) (Pudendal(Onuf n.) (Pudendal nerve)nerve) Symp T10-L1 P.Symp S2,3,4 (Interomed) Motor S2,3,4 (Onuf)
  6. 6. Categorization of VoidingCategorization of Voiding DysfunctionsDysfunctions Several Classifications….Several Classifications….  Clinical, Urodynamic,Clinical, Urodynamic, Pathophysiologic, Anatomical…Pathophysiologic, Anatomical…
  7. 7. Functional Classification (Functional Classification (WeinWein(( Failure to StoreFailure to Store Because of the BladderBecause of the Bladder  OveractivityOveractivity 1.1. Involuntary contractionInvoluntary contraction 2.2. Decreased ComplianceDecreased Compliance 3.3. CombinationCombination  Hypersensitivity (inflam, psych…)Hypersensitivity (inflam, psych…) Because of the outletBecause of the outlet  Anatomic incontinence (UDN-SUI)Anatomic incontinence (UDN-SUI)  Intrinsic sphincteric IncompetenceIntrinsic sphincteric Incompetence (Neurogenic or traumatic)(Neurogenic or traumatic)  CombinationCombination CombinationCombination Failure to EmptyFailure to Empty Because of theBecause of the BladderBladder  Hypotonia, Atony.Hypotonia, Atony. FibrosisFibrosis Because of the outletBecause of the outlet  Anatomic ObstructionAnatomic Obstruction (BPH, Stricture,…)(BPH, Stricture,…)  Functional:Functional: Dyssenergia (SmoothDyssenergia (Smooth or Striated Sphincter)or Striated Sphincter) CombinationCombination
  8. 8. NVD (Neurogenic VoidingNVD (Neurogenic Voiding DysfunctionsDysfunctions(( DefDef.: NVD are Abnormalities in the.: NVD are Abnormalities in the micturition cycle produced by differentmicturition cycle produced by different diseases of the nervous systemdiseases of the nervous system The NVD depend onThe NVD depend on::  The level of the neurologic lesionThe level of the neurologic lesion  The type of neurologic lesionThe type of neurologic lesion  The status of the UT prior to the lesionThe status of the UT prior to the lesion
  9. 9. General Patterns Of NVDGeneral Patterns Of NVD According To The Level Of The Lesion In The NervousAccording To The Level Of The Lesion In The Nervous SystemSystem
  10. 10. Levels of lesions in NSLevels of lesions in NS 1.1. Above Brain stemAbove Brain stem 2.2. Spinal CordSpinal Cord  Suprasacral spinal cord Above T6Suprasacral spinal cord Above T6  Suprasacral spinal cord Below T6 till S2Suprasacral spinal cord Below T6 till S2 CommonestCommonest  Sacral S2Sacral S2 33. Distal to the spinal cord. Distal to the spinal cord
  11. 11. General Patterns Of NVDGeneral Patterns Of NVD BladderBladder  Sensation (intact or lost)Sensation (intact or lost)  Detrusor (Overactive, underactive or atonic)Detrusor (Overactive, underactive or atonic) OutletOutlet  Smooth Sphincter (Synergic or dyssenergic)Smooth Sphincter (Synergic or dyssenergic)  Striated Sphincter (Synergic or dyssenergic)Striated Sphincter (Synergic or dyssenergic) Specific featuresSpecific features
  12. 12. C S L T T 6 S 2 NDO (Neurogenic DO), Synergic sphincters, intact sensations and voluntary sphincters e.g.. CVA NDO, Synergic smooth sphincter, Dyssenergic Striated sphincters lost sensations (after spinal shock) e.g. Trauma NDO, Dyssenergic Smooth & Striated sphincters lost sensations + Autonomic Hypereflexia e.g. Trauma Areflexia, CNR smooth sphincter, Fixed Striated sphincters lost sensations Areflexia, CNR smooth sphincter, Syn Striated sphincters lost sensations e.g. Disc U M N L L M N L
  13. 13. Spinal Cord InjuriesSpinal Cord Injuries  Spinal Cord ends atSpinal Cord ends at L1/2 junctionL1/2 junction  S2,3,4 Opposite T12S2,3,4 Opposite T12  Injuries at T11 and UpInjuries at T11 and Up = Suprasacral SCI= Suprasacral SCI  Injuries at L1 andInjuries at L1 and Below = Infrascral SCIBelow = Infrascral SCI  Injuries at T12 =Injuries at T12 = VariableVariable
  14. 14. RemarksRemarks  These features are the most typical forThese features are the most typical for each lesioneach lesion  They represent the common VD with aThey represent the common VD with a typical lesiontypical lesion  Variation in the clinical syndrome is veryVariation in the clinical syndrome is very commoncommon
  15. 15. Evaluation of a PatientEvaluation of a Patient with Neurogenicwith Neurogenic Voiding DysfunctionVoiding Dysfunction
  16. 16. The Neurourologic EvaluationThe Neurourologic Evaluation History: Stress Points:History: Stress Points:  History Prior To the current eventHistory Prior To the current event  LUTS (Storage & Voiding Symptoms)LUTS (Storage & Voiding Symptoms)  Associated Neurologic SymptomsAssociated Neurologic Symptoms  Sex and bowel symptomSex and bowel symptom  Questionnaires and DiariesQuestionnaires and Diaries
  17. 17. The Neurourologic EvaluationThe Neurourologic Evaluation Examination: Stress PointsExamination: Stress Points UrologicUrologic -Back: swelling, patches…-Back: swelling, patches… -Anal tone-Anal tone::  Intact + voluntary cont=: normal,Intact + voluntary cont=: normal,  Weak tone and voluntary or absent= sacral andWeak tone and voluntary or absent= sacral and infrasacral,infrasacral,  Preserved or increased and no voluntaryPreserved or increased and no voluntary control= suprasacralcontrol= suprasacral -P/V-P/V
  18. 18. The Neurourologic EvaluationThe Neurourologic Evaluation Examination: Stress PointsExamination: Stress Points NeurologicNeurologic  Mental Status, Gait…Mental Status, Gait…  Leveling:…Leveling:… 1.1. Motor power:Motor power: Weakness below the lesion +Weakness below the lesion + Hypertonia in UMNL and Hypotonia in LMNLHypertonia in UMNL and Hypotonia in LMNL 2.2. Sensation:Sensation: Lost below the lesionLost below the lesion 3.3. ReflexesReflexes Knee L 3-4, achilis L5-S2, BCR S2-4Knee L 3-4, achilis L5-S2, BCR S2-4
  19. 19. Sensory DermatomesSensory Dermatomes S2,3,4 L2,3 T 10 L1 T 6
  20. 20. Voiding DiaryVoiding Diary  It is a very important toolIt is a very important tool  It is no less important than UDNIt is no less important than UDN  It is the guide forIt is the guide for SelectingSelecting 1.1. the investigationthe investigation 2.2. the UDN testthe UDN test 3.3. the treatmentthe treatment
  21. 21. InvestInvest  Lab….Lab….  Radiolgic:Radiolgic:  PUT and U/S, IVPPUT and U/S, IVP  ACUGACUG  EndoscopyEndoscopy  UrodynamicsUrodynamics
  22. 22. UrodynamicsUrodynamics
  23. 23. Why UrodynamicsWhy Urodynamics??  Many neurophysiologic defects shareMany neurophysiologic defects share similar clinical presentations.similar clinical presentations.  If we treat the clinical condition withoutIf we treat the clinical condition without respecting the the neurophysiologic statusrespecting the the neurophysiologic status it might fail but more seriously might beit might fail but more seriously might be hazardous.hazardous.
  24. 24. examplesexamples  A 65 yrs old man complaining of weak stream notA 65 yrs old man complaining of weak stream not responding any more to alfa blockers. (which he has beenresponding any more to alfa blockers. (which he has been taking for 10 years). His PVR is 450 ml and his Qmax istaking for 10 years). His PVR is 450 ml and his Qmax is 6ml/sec.6ml/sec.  One ptn will benefit very much from TURP and the otherOne ptn will benefit very much from TURP and the other will not…. why?will not…. why?  If he has strong detrusor + low flow will benefit fromIf he has strong detrusor + low flow will benefit from TURPTURP  If he has a weak detrusor +low flow he will not benefitIf he has a weak detrusor +low flow he will not benefit from TURPfrom TURP  These data could not be known except with UDNThese data could not be known except with UDN
  25. 25. A 35 yrs old maleA 35 yrs old male  Had a fracture spine T11-12. IncontinentHad a fracture spine T11-12. Incontinent always wearing a condom. He does notalways wearing a condom. He does not feel urgency nor normal desire.feel urgency nor normal desire.  If you treat the clinical condition: eg AntiIf you treat the clinical condition: eg Anti cholinergic may end in ---Renal Failure!!!cholinergic may end in ---Renal Failure!!!  UDN : DO + low bladder capacity DLPPUDN : DO + low bladder capacity DLPP >40 + DESD so treatment would be…>40 + DESD so treatment would be…
  26. 26. 7575yrs old maleyrs old male  Mild Alzheimer’s complains of severeMild Alzheimer’s complains of severe frequency nocturia and urge incontinence.frequency nocturia and urge incontinence.  His stream is very weakHis stream is very weak  Qmax is 5 on a voided volume of 90 ccQmax is 5 on a voided volume of 90 cc  His prostate on US is 65 gmHis prostate on US is 65 gm  He underwent TURP and his conditionHe underwent TURP and his condition got worse…why?got worse…why?
  27. 27. So Urodynamics ToSo Urodynamics To  To elucidate the neurophysiologicalTo elucidate the neurophysiological changes that associates the clinicalchanges that associates the clinical conditioncondition  1. Complete the evaluation circle1. Complete the evaluation circle  2. Plan the treatment2. Plan the treatment  3. Monitor response3. Monitor response
  28. 28. UrodynamicsUrodynamics IndicationsIndications::  All Neurogenic Voiding DysfunctionAll Neurogenic Voiding Dysfunction (overt or occult NVD)(overt or occult NVD)  Selected Cases of Non neurogenic voidingSelected Cases of Non neurogenic voiding dysfunctiondysfunction
  29. 29. Neurogenic VDNeurogenic VD  OvertOvert: Strokes, Parkinson’s, Spine Injuries,: Strokes, Parkinson’s, Spine Injuries, Spina bifida overta..Spina bifida overta..  OccultOccult NVD: Mild dementia, DiabeticNVD: Mild dementia, Diabetic cystopathy, mild Disc disease, spinal cordcystopathy, mild Disc disease, spinal cord lesions (tumors, metastasis…),lesions (tumors, metastasis…),
  30. 30. Non-Neurogenic VDNon-Neurogenic VD Clear Voiding DysfunctionsClear Voiding Dysfunctions: BPE, Genuine SUI, Post: BPE, Genuine SUI, Post prostatectomy incontinence…prostatectomy incontinence… Rarely will need UDNRarely will need UDN However UDN is indicated if:However UDN is indicated if: BPE with CNS disease, Long standing DMBPE with CNS disease, Long standing DM  SUI mixed wit Urge Incontinence (Mixed UI)SUI mixed wit Urge Incontinence (Mixed UI) Complicated PPI: to evaluate response to treatmentComplicated PPI: to evaluate response to treatment Idiopathic VDIdiopathic VD commonest is IDOcommonest is IDO
  31. 31. So…So… UrodynamicsUrodynamics IndicationsIndications::  All neurogenic or suspected neurogenicAll neurogenic or suspected neurogenic VDVD  Select cases of non-neurogenic VDSelect cases of non-neurogenic VD  Idiopathic VDIdiopathic VD
  32. 32. RememberRemember  UDN does not treat, it helps you to treat  UDN does not give you solutions it answers question for you to give the solutions
  33. 33. That means that before requesting UDN 1. You have to decide on the questions to be answered 2. therefore design the study to obtain the answers to those questions. 3. Correlate the UDN study findings to the clinical condition
  34. 34. )Nitti and Combs, 1998(  1. Decide on questions to be answered before starting a study.  2. Design the study to answer these questions.  3. Customize the study as needed.
  35. 35. TerminologyTerminology
  36. 36. UrodynamicsUrodynamics What do we want from itWhat do we want from it?? 1.1. Is it a storage or emptying defect? orIs it a storage or emptying defect? or bothboth 2.2. What is the site of the defect? DetrusorWhat is the site of the defect? Detrusor or outlet or both?or outlet or both? 3.3. What is the type of the defect?What is the type of the defect? 4.4. What is the degree of the defect?What is the degree of the defect? 5.5. How will UDN determine the treatment?How will UDN determine the treatment?
  37. 37. UrodynamicsUrodynamics “Bear in mind“Bear in mind”” NittiNitti’s Principles:’s Principles:  A study that does not duplicate the ptnA study that does not duplicate the ptn symptom(s) is not diagnostic.symptom(s) is not diagnostic.  Failure to record an abnormality does notFailure to record an abnormality does not rule out its existencerule out its existence  Not all recorded abnormality are clinicallyNot all recorded abnormality are clinically significantsignificant
  38. 38. UrodynamicsUrodynamics  Components EvaluationComponents Evaluation 1.1. Storage functionsStorage functions 2.2. Emptying functionsEmptying functions
  39. 39. Evaluation of Storage FunctionEvaluation of Storage Function The Detrusor:The Detrusor: Filling Cystometry:Filling Cystometry:  Sensation:1Sensation:1stst sens., normal desire…..sens., normal desire…..  Compliance: ∆V/ ∆ PdetCompliance: ∆V/ ∆ Pdet  Motor activity: pressure rise, UIDC…Motor activity: pressure rise, UIDC… The outlet:The outlet:  DLPPDLPP  VLPPVLPP  UPPUPP
  40. 40. Filling CMGFilling CMG 1st desire Normal desire Strong desire Urgency Max Cyst Capacity
  41. 41. Filling CMGFilling CMG  Involuntary BladderInvoluntary Bladder ContractionsContractions
  42. 42. Filling CMGFilling CMG  ComplianceCompliance At 155 ml the P det is 45 cm = low compliance
  43. 43. OutletOutlet  DLPPDLPP  40 cm cuttoff40 cm cuttoff
  44. 44. OutletOutlet  VLPPVLPP Valslava + No Leak Valsa;va + Leak
  45. 45. Evaluation of Voiding FunctionEvaluation of Voiding Function  UroflowmetryUroflowmetry :: Max flow rate andMax flow rate and average flow rateaverage flow rate  Drawbacks!!!Drawbacks!!!  Siroky NomogramSiroky Nomogram
  46. 46. Evaluation of Voiding FunctionEvaluation of Voiding Function Pressure flow studies:Pressure flow studies:  Plots the urinary flow against the intravesicalPlots the urinary flow against the intravesical pressure.pressure.  Differentiates outflow obstruction from poorDifferentiates outflow obstruction from poor contractilitycontractility  Assess the Ext sphincter activity (EMG) at restAssess the Ext sphincter activity (EMG) at rest and during voidingand during voiding
  47. 47. Main abnormalities on VCMGMain abnormalities on VCMG  Low pressure low flowLow pressure low flow  High pressure low flowHigh pressure low flow  High pressure normal flowHigh pressure normal flow  DESDDESD
  48. 48.  Obstructed: Eg: BPEObstructed: Eg: BPE  Non ObstructedNon Obstructed Pressure FlowPressure Flow
  49. 49. Pressure Flow:Pressure Flow: NomogramsNomograms
  50. 50. DESDDESD
  51. 51. VideourodynamicsVideourodynamics Def:Def: UDN carried out under flouroscopic imagingUDN carried out under flouroscopic imaging IndicationsIndications::  When simultaneous evaluation of the structureWhen simultaneous evaluation of the structure and function of the urinary tract is needed toand function of the urinary tract is needed to made a diagnosis e.g.made a diagnosis e.g.  Complex bladder outlet obstruction (bladderComplex bladder outlet obstruction (bladder neck dysfunction, dyssenergianeck dysfunction, dyssenergia  Incontinence with unclear pathophysiologyIncontinence with unclear pathophysiology
  52. 52. PFS shows high pressure low flow pattern and simultaneousPFS shows high pressure low flow pattern and simultaneous fluroscopy at start of voiding shows narrowed prostatic fossafluroscopy at start of voiding shows narrowed prostatic fossa
  53. 53. RestRest StressStress RestRest LeakLeak VLPP + Fluoroscopic MonitoringVLPP + Fluoroscopic Monitoring
  54. 54. Treatment of VDTreatment of VD  The CauseThe Cause  The ConditionThe Condition
  55. 55. Treatment of VD…GuidelinesTreatment of VD…Guidelines  IdentifyIdentify the pathologythe pathology  SelectSelect the appropriate treatment starting with ; thethe appropriate treatment starting with ; the least invasive most effectiveleast invasive most effective  DefineDefine Goals?:Goals?: 1.1. Upper UT presevationUpper UT presevation 2.2. Control of infectionControl of infection 3.3. Adequate storage al low intravesical pressureAdequate storage al low intravesical pressure 4.4. Adequate emptying al low intravesical pressureAdequate emptying al low intravesical pressure 5.5. Adequate controlAdequate control 6.6. No catheter or stomaNo catheter or stoma 7.7. Social acceptabilitySocial acceptability
  56. 56. Treatment of VD…GuidelinesTreatment of VD…Guidelines  11stst : Identify: Identify the problemthe problem
  57. 57. Treatment of VD…GuidelinesTreatment of VD…Guidelines Storage DefectStorage Defect Because of the BladderBecause of the Bladder  OveractivityOveractivity 1.1. Involuntary contractionInvoluntary contraction 2.2. Decreased ComplianceDecreased Compliance 3.3. CombinationCombination  Hypersensitivity (inflam, psych…)Hypersensitivity (inflam, psych…) Because of the outletBecause of the outlet  Anatomic incontinence (Genuine SUI)Anatomic incontinence (Genuine SUI)  Intrinsic sphincteric IncompetenceIntrinsic sphincteric Incompetence (Neurogenic or traumatic)(Neurogenic or traumatic)  CombinationCombination CombinationCombination Emptying DefectEmptying Defect Because of theBecause of the BladderBladder  Hypotonia, Atony.Hypotonia, Atony. FibrosisFibrosis Because of the outletBecause of the outlet  Anatomic ObstructionAnatomic Obstruction (BPH, Stricture,…)(BPH, Stricture,…)  Functional:Functional: Dyssenergia (SmoothDyssenergia (Smooth or Striated Sphincter)or Striated Sphincter) CombinationCombination
  58. 58. Botox
  59. 59. Botox
  60. 60. Thank YouThank You

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