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1 婦女尿失禁 (Female urinary incontinence) 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

3 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

4 男女大不同

5 男女大不同

6 男女大不同

7 Urogynecology Stress urinary incontinence Pelvic organ prolapse (POP)

8 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:

9 Bladder & Urethra Normal Storage Voiding Bladder Relaxed Contracted Urethra contracted relaxed

10 Normal micturition cycle 尿道壓力膀胱壓力 Stanton SL,Tanagho EA 1986 Springer-Verlag

11 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

12 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

13 尿失禁種類應力性尿失禁 (stress urinary incontinence) 急迫性尿失禁 (urge urinary incontinence) 混合型尿失禁 (mixed urinary incontinence) 溢出性尿失禁 (overflow incontinence) 其他類型 : 脊髓損傷瘺管等

14 應力性尿失禁 (stress urinary incontinence,sui) 為什麼我運動時都會漏尿? 我咳嗽也會漏尿!

15 急迫性尿失禁 (urge incontinence)

16 應力性尿失禁 (1) 正常 (2) 尿失禁

17 急迫性尿失禁

18 混合性尿失禁

19 溢出性尿失禁

20 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

22 Bladder & Urethra Normal Storage Voiding Bladder Relaxed Contracted Urethra contracted relaxed Abnormal Storage Voiding Bladder Overactive Underactive Urethra Incompetent under stress Inappropriate relaxaed Acontractile Functional or anatomic obstruction

23 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

28 Cough stress test Standing position Squatting position

30 子宮脫垂嚴重度第一度第二度子宮切除後之陰道穹窿脫垂第三度

31 尿動力學檢查 (Urodynamic study) Solar with video system 奇美 B2 婦女影像尿動力檢查室

32 尿動力學檢查 Bladder filled with 200 ml, I'm Straining with Increased Force up to Leak! Pves Pabd Leak Qura 30 Rectum Bladder

33 20 ml FD ND SD Urodynamic study: Cystometry EMG Pura UU Pves Speaking Cough Cough RH Cough Pabd UIDC Pdet Leak Qura Vinf Time 1 min/div ml

34 Urodynamic stress incontinence (USI) Nygaard & Heit 2004 Obstet Gynecol

35 Urodynamic stress incontinence (USI)

36 Detrusor overactivity (DO) w/wt incontinence Nygaard & Heit 2004 Obstet Gynecol

37 Cystometry: DO without incontinence

38 Cystometry: DO with incontinence

39 Video-urodynamic study Laborie Dorado

40 選擇治療方式物理治療藥物治療手術治療

41 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

42 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 timeintensive to be effective 3 1 Fantl, JA, et al. JAMA. 1991: Burgio KL, et al. JAMA. 1998: Subak LL, et al. Obstet Gynecol. 2002: Burgio KL, et al. Obstet Gynecol. 2003:

43 Nonsurgical Management of UI: Lifestyle Modifications Increase or decrease in fluid intake Reduction of dietary irritants Increase in dietary fiber Weight reduction

44 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

45 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 (Colgate Medical, Berkshire) *Herbison P, et al. The Cochrane Database of Syst Rev. 2002:CD002114

46 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

47 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.

48 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

49 凱格爾運動生理回饋治療

50 Demo case

51 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 rate 1 Other studies: No more effective than PFMT alone 2,3 1 Iselin CE, Webster GD. Urol Clin North Am. 1998: Goode PS, et al. JAMA. 2003: Spruijt J, et al. Acta Obstet Gynecol Scand. 2003:

53 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

54 藥物治療 Peripheral Action of neurotransmitters in the micturition cycle

55 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

56 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

57 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

58 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

59 台灣地區近十年來尿失禁手術改變驅勢 n The trend of different surgical RPU 59.5 Sling 59.4 TVTs MUS Kelly 59.3 Needle LS Injection year Wu MP, Tang CH, et. al 2008 Int Urogyn J

60 手術理論基礎 (Ulmsten Integral Theory) PUL: pubo-urethral lig.

61 平時用力時

63 第一代 : 經恥骨後系統 (Retropubic)

TVT vs TVT-O Inside-out de Leval Outside-in Delorme de Leval et al. 2003 Eur Urol Bonnet et al.

64 TVT vs TVT-O Inside-out de Leval Outside-in Delorme de Leval et al Eur Urol Bonnet et al J Urol Waltregny et al J Urol Delorme E. Prog 2001 Urol Delmas V et al Eur Urol

65 第二代 : 經閉孔膜系統 (Transobturator)

66 第三代 : 單一傷口 ( 無出口 ) 系統 (Single incision sling, SIS)

67 第三代 TVT-Secure, MiniArc 迷你手術

68 The evolution of midurethral sling (MUS) 1st generation: Supra-pubic TVT, SPARC, IVS Endoscopic bladder neck suspension (EBNS) 3rd generation: Single-incision TVT-secure, MiniArc 2nd generation: Trans-obturator TVT-O, Monarc Tradition bladder-neck sling Kelly plication TVT: tension-free vaginal tape TVT-O: tension-free vaginal tape -obturator SPARC: suprapubic arc

69 你 ( 妳 ) 怎麼念呢?

70 膀胱過動症 (overactive bladder, OAB) -- 臨床上的問題及處理急尿頻尿急迫性尿失禁? 膀胱過動症??

71 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

72 急尿 (urgency)

73 急迫性尿失禁 (urge incontinence)

74 Problems on current overactive bladder (OAB) symptom syndrome 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?

75 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 81

76 Core symptom 3 distinctive OAB subtypes : 1. OAB dry 2. OAB wet 3. OAB with voiding difficulty 82 Hung MJ: 2006 J Urol 176:636-40

77 Hung MJ J Urol 2006;176:

78 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

79 Impact on female adaptation by OAB subtypes Hung MJ J Urol 2006;176:636-40

80 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,

81 The urgency of the problem and the problem of urgency in the overactive bladder Urge Desire to void Normal sensation physiology Urgency 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,

82 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 Incont Pelvic Floor Dysfunct 88

83 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 89 Chapple et al. BJU Int 2005

84 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 90 Chapple et al. BJU Int

85 OAB Definition in 2010 OAB: Urgency, with or without urgency incontinence, usually with increased frequency and nocturia Urge syndrome urgency syndrome Frequency: daytime frequency 91

86 Lack of symmetry in both the term and definition between Daytime frequency and night-time frequency. International Journal of Urology 2008,15;

OAB Symptoms Frequency Daytime frequency:

they void too often by day Nocturia (urination

wake up at night one or more times to void

desire to pass urine that is difficult to

87 OAB Symptoms 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 Urgency (core symptom) Sudden, compelling desire to pass urine that is difficult to defer Urgency Incontinence Involuntary leakage preceded by urgency OAB

88 2. Do we need urodynamics for OAB symptoms

89 Urodynamics in OAB

90 The need of urodynamics in OAB A total of 4,500 women 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

91 Digesu GA 2003 Neurourol

93 Autonomic Efferent Innervation Contributing to Bladder Contraction and Urine Storage Ouslander JG 2004

94 Antimuscarinic mechamism of Detrusor muscle action 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

95 Muscarinic Receptor Distribution CNS Iris/ciliary body Lacrimal gland Blurred vision Dry eyes Dizziness Somnolence Cognitive impairment, especially memory Narrow angle glaucoma Contraindication for all antimuscarinics Salivary glands Heart Stomach and esophagus Colon Tachycardia Bladder (detrusor) Dry mouth Dyspepsia Constipation

96 Affinity for muscarinic receptor subtypes M 1 Physiologic Effect The receptor may play an important role in cognition Clinical Impact M 1 : cognitive adverse effects M 2 80 % (detrusor muscle) : M 2 detrusor smooth muscle contraction (indirectly): muscle relaxation of β- adrenoceptors M 3 20% (detrusor muscle): M 3 the main receptor subtype responsible for normal micturition contraction M 2 : cardiac adverse effects Overly aggressive M 3 blockade constipation M 4 M 5 Not present in the bladder in significant numbers Unknown

97 Structure of antimuscarinics Feature Physiologic Effect Clinical Impact Tertiary amine Allows transfer across the BBB into CNS Allows good absorption across GI tract May result in adverse cognitive effects Particularly among elderly patients Quaternary amines Limits transfer across the BBB into CNS Limits absorption across GI tract Reduces the potential for cognitive adverse effects

98 Solifenacin Tertiary amine Trospium Quarternary amine

99 Tertiary amines Atropine Oxybutynin (Ditropan) Propiverine (Urotrol) Solifenacin (Vesicare) Darifenacin Tolterodine (Detrusitol) Fesoterodine- active metabolite 5-HMT (5-hydroxymethyl- tolterodine)

100 Quaternary amines Trospium chloride Non-selectivity for M receptor subtype Low biological availability Cross BBB to a limited extent A low incidence of CNS side-effects Few cognitive effect Producing well known peripheral antimuscarinic side-effects Constipation, tachycardia, and dry mouth Trospium ER: once daily Launched in 2008 Lower max plasma concentration Decrease incidence of side-effect and increase tolerability

101 Antimuscarinics Level Grade 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)

102 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

103 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.

Selectivity for bladder M receptor over salivary

104 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

105 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: ** Diokno AC, et al. Mayo Clin Proc. 2003:

106 Nonsurgical Management of UI: Trospium Chloride, Darifenacin, Solifenacin Succinate 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:

Solifenacin (Vesicare) Launched in Europe in 2004 Competitive, selective M1 and M3 receptor antagonist Two formulations: 5 mg, 10 mg Higher potency

107 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

108 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 Chapple CR et al, (2005): Eur Urol,48;3 :464- Screening Baseline reading Option to request increase dose Solifenacin 5mg + 5mg ASSESSMENT Solifenacin 5mg Solifenacin 5mg Placebo Tolterodine ER + Placebo Tolterodine ER Tolterodine ER PRI Treatment Week -2 Week 0 Baseline Week 4 Week 8 Week 12

109 Results of the STARTrial Chapple CR et al, Eur

110 Treatment Outcomes in the STAR Study: A Subanalysis of Solifenacin 5 mg and Tolterodine ER 4 mg Chapple CR Eur Urol 2007; 52:1195-

111 Hormone Level of evidence Grade of recommendation Estrogen 2 C Desmopressin * 1 A *Nocturia

112 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 1 Fantl JA, et al. Obstet Gynecol. 1994: Al-Badr A, et al. J Obstet Gynaecol Can. 2003: Hendrix SL, et al. JAMA. 2005: Steinauer JE, et al. Obstet Gynecol. 2005:

113 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: 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

114 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

115 Pharmacotherapy for overactive bladder. Igawa 2000 Urol 55 (supp 5A): 47

116 Toxins Botulinum toxin (neurogenic) Botulinum toxin (idiopathic) Capsaicin (neurogenic) Resiniferatoxin (idiopathic) Level of evidence Grade of recommendation 2 A 3 B 2 C 2 C

117 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

118 Mechanism of action of botulinum toxin Normal release of Ach at the neuromuscular junction SNARE: N-ethylmaleimide sensitive factor attachement receptor Ho MH et al 2005 Curr Opin Obs Gyn

119 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

in 30 idiopathic detrusor overactivity (IDO) patients

at a dose of 200 U revealed therapeutic results (85%

120 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)

121 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?

122 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

123 子宮脫垂嚴重度第一度第二度子宮切除後之陰道穹窿脫垂第三度

124 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

125 膀胱過動症與骨盆鬆弛 De Boer 2010 Neurourol Urod 有骨盆鬆弛者比無骨盆鬆弛者膀胱過動症出現比率為倍

126 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 Urody

127 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

128 Pelvic suppport structures 6 Ligaments, 2 Fascia, 1 Ring Pericervical ring Cardinal ligament arcus tendineus fasciae pelvis Rectovaginal fascia Pubocervical ligaments TeLinde s Operative Gynecology

129 Tension-free vaginal mesh (TVM)

130 無張力人工網膜植入術 Tension-free Vaginal Mesh (TVM)

131 OP record for TVM +/- TVT-O A B Monarc or TVT-O or Miniarc Prolift (ant) or Perigee Prolift (post) or Apogee Gynecare, J&J AMS; Tyco Preserved uterus Hysterectomized

132 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放置時間短美觀尿失禁 & 骨盆鬆弛治療無壓力

133 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 ( 倍 ) De Boer 2010 Neurourol Urodyn

134 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 ( 倍 )

135 夢想不該隨著年紀愈大而縮水

136 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.

137 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.

138 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).

139 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).

140 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

141

142 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 Dry mouth Events Use regular or sugar-free candy, lozenges, gum or mouthwash. Increase fluid intake (six 8-oz glasses daily).

143 Nonsurgical Management of UI: Managing Anticholinergic Adverse Dry mouth Events 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.

Introduction to urogynecology

Introduction to urogynecology 婦女泌尿暨骨盆醫學介紹 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)