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

“The bladder is an unreliable witness” Stanton 1984

URODYNAMICS ”Studies provide an objective describtion of lower urinary tract function and dysfunction in terms of qualitative and quantitative variables” ICI 2005

URODYNAMICS ”The study of the function and dysfunction of the urinary tract by any appropriate method” non-invasive invasive ICS 1988

URODYNAMICS ”Urodynamic studies should be performed and reported in accordance with the standards (good urodynamic practices) of the ICS” ICS 2005

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)

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

URETHRAL TRYK Invasiv (ikke standardiseret) Alle parametre viser stor overlap mellem raske og ”syge” Lave værdier (LPP < 60 cm H2O og MUCP < 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).

BILLEDDIAGNOSTIK Der er ikke indikation for BD af øvre urinveje ved non-neurogen inkontinens PVR kan måles ved abdominal, vaginal eller transperineal UL Blærevægstykkelse >5 mm er correleret til DO BD har endnu ikke klare indikationer ved udredning af non-neurogen urininkontinens bortset fra måling af PVR

RISIKOFAKTORER VED MIDURETHRAL SLYNGER CURE RATE Alder (de novo urgency) BMI (> 35) Tidligere operation for inkontinens MUI DO BN mobilitet “ISD” (LPP < 60 cm H2O, MUCP < 20 cm H2O) (TVT v. TO?) VOIDING DIFFICULTIES PVR Q-max (TO-TVT) TVT v TO

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

ANDET

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

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

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