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
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
Normal micturition cycle 尿道壓力 膀胱壓力 Stanton SL,Tanagho EA 1986 Springer-Verlag
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 (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
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!
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 Urethra Incompetent under stress Inappropriate relaxaed Acontractile Functional or anatomic obstruction
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 第一度 第二度 子宮切除後之陰道穹窿脫垂 第三度 www.moondragon.org/obgyn
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
尿動力學檢查 Bladder filled with 200 ml, I'm Straining with Increased Force up to Leak! Pves Pabd 60 80 100 120 Leak Qura 30 Rectum Bladder
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 0 100 200 300 400 500 600 ml
Urodynamic stress incontinence (USI) Nygaard & Heit 2004 Obstet Gynecol
Urodynamic stress incontinence (USI)
Detrusor overactivity (DO) w/wt incontinence Nygaard & Heit 2004 Obstet Gynecol
Cystometry: DO without incontinence
Cystometry: DO with incontinence
Video-urodynamic study Laborie Dorado
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 timeintensive to be effective 3 1 Fantl, JA, et al. JAMA. 1991:609-613. 2 Burgio KL, et al. JAMA. 1998:1995-2000. 3 Subak LL, et al. Obstet Gynecol. 2002:72-78. 4 Burgio 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 (Colgate Medical, Berkshire) *Herbison P, et al. The Cochrane Database of Syst Rev. 2002:CD002114
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
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. 1998:625-645. 2 Goode PS, et al. JAMA. 2003:345-352. 3 Spruijt J, et al. Acta Obstet Gynecol Scand. 2003:1043-1048.
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
藥物治療 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
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
台灣地區近十年來尿失禁手術改變驅勢 n The trend of different surgical 1200 1000 800 600 400 200 RPU 59.5 Sling 59.4 TVTs MUS 59.79 Kelly 59.3 Needle 59.6 59.71 LS Injection 59.72 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 year 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 (Retropubic)
TVT vs TVT-O Inside-out de Leval Outside-in Delorme 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 (Transobturator)
第三代 : 單一傷口 ( 無出口 ) 系統 (Single incision sling, SIS)
第三代 TVT-Secure, MiniArc 迷你手術
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
你 ( 妳 ) 怎麼念呢?
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??
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)
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?
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
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
Hung MJ J Urol 2006;176:636-40 83
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
Impact on female adaptation by OAB subtypes Hung MJ J Urol 2006;176:636-40
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 86
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,
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 88
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
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
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
Lack of symmetry in both the term and definition between Daytime frequency and night-time frequency. International Journal of Urology 2008,15;35-43 92
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
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
Digesu GA 2003 Neurourol
Autonomic Efferent Innervation Contributing to Bladder Contraction and Urine Storage Ouslander JG 2004
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
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
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
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
Solifenacin Tertiary amine Trospium Quarternary amine
Tertiary amines Atropine Oxybutynin (Ditropan) Propiverine (Urotrol) Solifenacin (Vesicare) Darifenacin Tolterodine (Detrusitol) Fesoterodine- active metabolite 5-HMT (5-hydroxymethyl- tolterodine)
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
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)
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 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. 2004:1919-1924.
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 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
Results of the STARTrial Chapple CR et al, Eur
Treatment Outcomes in the STAR Study: A Subanalysis of Solifenacin 5 mg and Tolterodine ER 4 mg Chapple CR Eur Urol 2007; 52:1195-
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 1 Fantl JA, et al. Obstet Gynecol. 1994:12-18. 2 Al-Badr A, et al. J Obstet Gynaecol Can. 2003:567-574. 3 Hendrix SL, et al. JAMA. 2005:935-948. 4 Steinauer 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
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
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 SNARE: N-ethylmaleimide sensitive factor attachement receptor Ho MH et al 2005 Curr Opin Obs Gyn
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 第一度 第二度 子宮切除後之陰道穹窿脫垂 第三度 www.moondragon.org/obgyn
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 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 2.1-5.8 倍
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
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
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
Tension-free vaginal mesh (TVM)
無張力人工網膜植入術 Tension-free Vaginal Mesh (TVM)
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
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
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
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
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). 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.