女性不同类型尿失禁临床及尿动力学特点

目的 探讨女性不同类型尿失禁临床及尿动力学特点，提高临床诊治水平。方法 对76例女性患者常规行尿动力学检查，包括尿流率、压力流率研究、尿道压力测定、漏尿点压测定。结果 76例患者中，压力性尿失禁30例，运动紧迫性尿失禁15例，反射性尿失禁19例，混合型压力性／紧迫性尿失禁2例，不稳定尿道3例，假性尿失禁7例。运动紧迫性尿失禁中，DLPP≥40cmH2O者14例，均有不同程度双肾积水。结论 腹压漏尿点压测定可以协助确定压力性尿失禁的手术方式。神经性膀胱尿道功能障碍和膀胱出口梗阻均可能出现膀胱顺应性下降，逼尿肌漏尿点压可以帮助决定膀胱顺应性下降时手术治疗时机。当逼尿肌漏尿点压≥40cmH2O，或者膀胱充盈200ml时逼尿肌压力≥40cmH2O时，必须进行治疗，否则会导致上尿路损害。     

压力性尿失禁合并糖尿病患者的尿动力学研究

目的 探讨尿动力学检查在压力性尿失禁合并糖尿病中的诊断意义。方法 采用德国Ellipse尿动力检测仪对58例女性压力性尿失禁合并糖尿病患者及40例单纯压力性尿失禁患者进行尿动力学检测,参照不同的糖尿病病程,明确不同时期尿动力学的特征性改变。结果 实验组与对照组相比,两组中以McGuire法分型的各型腹压漏尿点所占百分比具有明显差异;糖尿病病程大于2年患者的尿动力学参数与单纯SUI间差异具有统计学意义(P<0.05),最大尿流率、最大尿流率时逼尿肌压力随病程的增加而降低,而强烈排尿感容量、剩余尿量、最大膀胱测压容量及初始尿意容量均随病程的增加而增加。结论 尿动力学检查的各项指标结合糖尿病病程临床资料,有助于判断压力性尿失禁伴有何种膀胱功能的改变,对正确的诊断及后续治疗具有重要意义。     

尿动力学联合膀胱尿道造影在女性压力性尿失禁诊断中的价值

目的探讨尿动力学检查联合排泄性膀胱尿道造影在女性压力性尿失禁诊断中的应用价值。方法回顾性分析56例临床诊断为女性压力性尿失禁（SUI）的患者,年龄（59．2±8．2）岁,每例均行尿动力学和排泄性膀胱尿道造影检查,评估膀胱顺应性、逼尿肌稳定性、尿道压、膀胱及尿道的形态。鳍杲尿动力学检查提示最大尿流率（33．6±7．7）mL／s,残余尿（17．8±14．7）mL,膀胱顺应性正常,膀胱容量（356．3±99．3）mL,33例测得腹压漏尿点压（49．8±17．6）cmH2O,最大尿道闭合压（47．4±10．5）cmH2O,功能性尿道长度（2．6±0．6）cm。相关性分析显示病程与腹压漏尿点压高度负相关（r=-0．816,P〈0．01）。排泄性膀胱尿道造影见膀胱颈及近端尿道下移34例,膀胱尿道后角变钝或消失44例,静息期膀胱颈和近端尿道呈漏斗形7例,咳嗽时47例见造影剂从尿道溢出。结论在无影像尿动力学设备的单位,尿动力学检查和排泄性膀胱尿道造影联合应用对SUI的诊断和术前评估具有重要的价值,比单用一种方法更具有临床意义。     

女性压力性尿失禁的诊治进展

女性压力性尿失禁(SUI)指喷嚏、咳嗽等腹压增高时出现不自主的尿液从尿道外口漏出。体征是在腹压增加时观察到尿液不自主地从尿道流出,且腹压下降时漏尿自动停止。其尿动力学检查表现为充盈性膀胱测压时,在腹压增高且无逼尿肌收缩的情况下出现不自主漏尿。目前临床应用最广泛的治疗是经阴道无张力中段尿道吊带术(MUS)。规范化SUI的诊疗流程具有非常重要的意义,更微创有效地预防和治疗方法有待进一步探索。     

增加膀胱容量改变Valsalva漏尿点压力

作者对膀胱容量对漏尿点压力的影响进行了研究，以明确测定漏尿点压力时理想的膀胱容量。对５２例平均年龄５２岁的女性压力性尿失禁患者分别进行了影像尿动力学检查，根据影像标准其中Ⅰ型压力性尿失禁１２例、Ⅱ型２０例、Ⅲ型２０例，每增加５０ｍｌ膀胱容量测定漏尿点...     

经阴道无张力性尿道中段悬吊术治疗女性压力性尿失禁10例分析

目的：探讨经阴道无张力性尿道中段悬吊术(TVT)在治疗女性压力性尿失禁中的意义。方法：10例患者，年龄45—58岁，平均48．4岁。临床表现为用力、咳嗽等时尿液不自主流出。病史4个月-15年。经详细地尿动力学检查证实为压力性尿失禁。行腹压漏尿点压(abdominal leak-point pressure，ALPP)测定，按照McGuire的方法分型，ALPP＞9．81kPa(I型)2例，ALPP6．38—9．81kPa(Ⅱ型)3例，ALPP＜6．38kPa(Ⅲ型)5例。结果：术后10例均无尿失禁，8例患者拔除导尿管当日即可顺利排尿，1例出现尿潴留，1例膀胱穿孔。结论：TVT手术安全易行，手术时间短，创伤小，患者康复快，治疗压力性尿失禁近期效果确切，远期疗效有待进一步研究。     

腹腔镜阴道悬吊术治疗女性压力性尿失禁

我们采用腹腔镜行腹膜前阴道悬吊术治疗压力性尿失禁 1例 ,随访近 2个月 ,近期疗效满意。1　资料与方法1 .1 　 临床资料患者 ,女 ,63岁。咳嗽、大笑时尿失禁 6年 ,近 1年明显加重。 2 0 0 1年 1月 1 6日入院。尿动力学检查 :最大尿流率 30 ml/ s,膀胱逼尿肌功能正常 ,尿道压降低。诱发试验及膀胱颈抬高试验阳性。1 .2 　 手术方法同年 1月 1 9日手术。气管插管全身麻醉 ,患者取 2 0°头底脚高截石位。腹腔镜穿刺点选择在脐 ( A点 )及脐与左右髂前上棘连线中点 ( B、C点 )。在脐下缘作 2 cm弧形切口 ,分别切开皮肤、皮下组织及腹直肌前鞘 …     

自体干细胞注射治疗女性压力性尿失禁的实验研究

目的 探讨自体肌肉干细胞注射治疗女性压力性尿失禁的可行性.方法 采用双侧卵巢切除和反复阴道扩张的方法,构建雌性SD大鼠压力性尿失禁动物模型.45只大鼠分3组,正常对照组15只,尿失禁模型30只,其中模型对照组15只,细胞注射治疗组15只.细胞注射治疗组建立模型后第2个月末接受自体肌肉干细胞尿道周围注射治疗.注射治疗组治疗1个月后,测定3组大鼠腹压漏尿点压,同时取近段尿道组织,HE染色观察形态学变化.结果 尿失禁模型组腹压漏尿点压(n=12)(26.4±2.7)cm H2O、正常对照组(n=14)(78.4±3.1)cm H2O、细胞注射治疗组(n=11)(58.8±2.4)cm H2O.3组间两两比较差异均有统计学意义.细胞注射后局部尿道壁肌层增厚、肌纤维增强.结论 自体肌肉干细胞注射治疗能明显提高压力性尿失禁动物模型的腹压漏尿点压,并使注射位点尿道壁肌层得到增强.注射细胞数量和注射后对膀胱功能的远期影响需进一步研究.     

真性尿失禁的手术治疗进展

根据国际尿控协会(ICS)的定义,尿失禁指尿液自尿道不自主的流出[1].临床上尿失禁主要表现为压力性尿失禁(SUI),急迫性尿失禁(UUI)及混合性尿失禁(MUI). 真性尿失禁(GSI)在临床上属于压力性尿失禁范畴,又称真性压力性尿失禁(GSUI).当用力、咳嗽、打喷嚏等动作导致腹压增加时,腹压传入膀胱使膀胱内压升高而逼尿肌并无收缩,当膀胱内压大于尿道压,出现尿液不自主流出,称为GSUI.膀胱颈部及尿道过度移动、尿道括约肌功能不足,均可导致GSI.男女均存在GSI,不过女性GSI患者远多于男性.女性GSI常是由于盆底支撑组织功能不全所引起,男性GSI常继发于前列腺疾病手术所导致的尿道括约肌功能损害.随着老年男性人口的增加,手术治疗前列腺疾患的数量也相应增多,男性GSI的比例也相应增加.     

延长和缩窄后尿道治疗女性压力性尿失禁(附12例报告)

目的 提高女性压力性尿失禁的手术疗效。方法 压力性尿失禁患者12例，根据Lap1ace定律，参考Campbell—Young手术方法，行后尿道及膀胱前壁切开，后尿道、膀胱颈及三角区裁剪宽约1．5cm壁瓣，缝合成管状，延长和缩窄后尿道。结果 术后平均随访8．8年，11例完全控制排尿，无剩余尿，远、近期效果一致；1例于用力增加腹压时，有极少量尿溢出。结论 延长和缩窄后尿道法治疗女性压力性尿失禁简单、有效、安全。     

The volume at which women leak first on urodynamic testing is not associated with quality of life, measures of urethral integrity or surgical failure

PURPOSE: We determined if the bladder volume at which urodynamic stress incontinence is first detected is related to preoperative quality of life, urethral sphincter assessment or surgical outcome in women undergoing continence surgery. MATERIALS AND METHODS: Charts of consecutive women who underwent a sling or Burch procedure were reviewed. Preoperative and postoperative assessment included the Incontinence Impact Questionnaire and Urogenital Distress Inventory. Urodynamic stress incontinence volume is the bladder volume at which urodynamic stress incontinence was first detected. Women were divided into 4 groups according to urodynamic stress incontinence volume, and compared with respect to maximum urethral closure pressure, Valsalva leak point pressure, Incontinence Impact Questionnaire and Urogenital Distress Inventory. Urodynamic stress incontinence persistence was evaluated only in patients who had sling surgery. RESULTS: A total of 168 women were recruited for the study. Urodynamic stress incontinence volume was 100 ml for 31% of women, 200 ml for 17%, 300 ml for 17% and 400 ml or greater for 35%. Baseline and postoperative Urogenital Distress Inventory, Incontinence Impact Questionnaire, maximal urethral closure pressure and Valsalva leak point pressure did not differ by urodynamic stress incontinence volume. Among the 116 patients who had the sling procedure, urodynamic stress incontinence persistence did not differ by urodynamic stress incontinence volume (p=0.72). CONCLUSIONS: Women who demonstrate urodynamic stress incontinence at lower bladder volumes do not report greater bother from incontinence than women who leak at higher volumes, suggesting leakage severity on urodynamics is not an adequate reflection of incontinence related quality of life.     

Value of leak point pressure study in women with incontinence

PURPOSE: We assessed the relationship between cough leak point pressure and Valsalva leak point pressure with stress incontinence and detrusor overactivity. MATERIALS AND METHODS: This prospective study was performed on 109 women with urinary incontinence who underwent urodynamic assessment from December 2003 to June 2005. We recorded cough leak point pressure and Valsalva leak point pressure by asking the patient to cough and to perform a Valsalva maneuver at maximum cystometric capacity until urine loss was directly observed and recorded by the machine. Women with normal urodynamic results or spontaneous voiding during examination were excluded fro analysis. Results were entered in the urodynamic database and analyzed using SPSS(R) release 13.0. RESULTS: Of the 109 women in the study 61 (56%) had stress incontinence, 21 (19%) had detrusor overactivity and 27 (25%) had mixed incontinence. All women with stress incontinence demonstrated leak at cough leak point pressure but 40 women (66%) did not leak with the Valsalva maneuver. Of the 21 patients who had detrusor overactivity 16 (76%) did not leak at cough leak point pressure whereas 17 (81%) leaked with the Valsalva maneuver. In the group of 27 women with mixed incontinence all leaked with cough at cough leak point pressure but only 17 (63%) leaked with the Valsalva maneuver. CONCLUSIONS: Women with stress incontinence diagnosed with urodynamics leaked more at cough leak point pressure than the Valsalva maneuver, and women with detrusor overactivity leaked less at cough leak point pressure and more with the Valsalva maneuver.     

Evaluation of minimally invasive analysis system for cough leak point pressure measurement

PURPOSE: Leak point pressure (LPP) measurement has become standard in the diagnosis of stress urinary incontinence. Leak point pressure is determined by increasing abdominal pressure, which can be done with a Valsalva maneuver or coughing, that is Valsalva LPP and cough LPP (CLPP). It may be influenced by catheter size, bladder volume and interobserver variability. A new, computerized LPP measuring technique for routine use in daily urodynamic practice was tested at a female unit urodynamic practice to evaluate female urinary incontinence. MATERIALS AND METHODS: A total of 28 female patients with a mean age of 54.07 years (range 23 to 82) and urinary incontinence underwent a new, minimally invasive measurement of the cough leak point. Measurements are made with the patient standing and repeated 3 times per patient. Additionally, parameters of the corresponding leak were recorded simultaneously. All patients underwent new CLPP measurement and a standard, complete urodynamic investigation, including filling cystometry with abdominal LPP and urethral pressure profile at rest. Statistical evaluation was done by linear regression analysis and the correlation coefficients among CLPP, age, standard abdominal LPP and maximum urethral pressure, and among the 3 measurements for each patient. RESULTS:: The assignment of leakage to the pressure signal presented no problem. All CLPP data were reproducible in the 3 repeated measurements per patient. No correlation was seen between CLPP and abdominal LPP or the urethral pressure profile. CONCLUSIONS: The study confirm that the CLPP is a practicable, consistent and minimally invasive method in routine use. Clinical use is easy and reproducible, and only 1 catheter is required for measurement.     

Removal of transurethral catheter during urodynamics may unmask stress urinary incontinence

PURPOSE: The measurement of Valsalva leak point pressure may have an important role in the treatment algorithm of women with stress urinary incontinence. However, some patients with stress urinary incontinence may not have leakage during standard urodynamic studies and, thus, the Valsalva leak point pressure cannot be determined. We hypothesized that the transurethral catheter may inhibit leakage during urodynamics. MATERIALS AND METHODS: We evaluated 21 consecutive women presenting with complaints of stress urinary incontinence who failed to have leakage on urodynamic studies. Bedside cystometry was performed, followed by urodynamics using a 6Fr transurethral catheter. When stress urinary incontinence was not noted, the catheter was removed and the Valsalva leak point pressure was measured using the intraabdominal pressure catheter. RESULTS: No woman had leakage on urodynamic studies with the catheter in place, although 11 of 21 had leakage after the catheter was removed and 15 had leakage on bedside cystometry. All 11 patients with leakage at catheter removal showed leakage on bedside stress testing. Mean Valsalva leak point pressure in those with leakage was 67 cm. water. CONCLUSIONS: Patients with a history of stress urinary incontinence and those with a positive bedside stress test who do not have leakage during a Valsalva maneuver on urodynamic studies should repeat the Valsalva maneuver with the catheter out. This technique may unmask stress urinary incontinence and allow the measurement of Valsalva leak point pressure.     

Urodynamic assessment of patients with stress incontinence: how effective are urethral pressure profilometry and abdominal leak point pressures at case selection and predicting outcome?

PURPOSE OF REVIEW: Disagreement exists as to the extent of evaluation required prior to offering surgical intervention for the treatment of stress urinary incontinence in women. While few would argue that additional information can be gleaned from a properly performed urodynamic investigation, it remains unclear exactly which women would most benefit from such preoperative study, and if urodynamic evaluation definitively improves treatment outcome. Since such invasive studies may not be widely available in certain areas, can be costly, and are associated with a low, but defined risk of bladder infection, it is imperative that the appropriate indication for preoperative urodynamic evaluation be carefully defined. This review highlights recent reports and controversies concerning the use of urodynamics (focusing on leak point pressure testing and urethral pressure profilometry) prior to surgical treatment for stress urinary incontinence. RECENT FINDINGS: There remains no clear consensus as to whether urodynamic testing enhances surgical outcome of stress urinary incontinence treatments by improving case selection or altering the surgical approach based on study findings. As treatment strategies for stress urinary incontinence have developed over the last several years to a more uniform approach, it is less clear that the severity of stress urinary incontinence, based on either abdominal leak point pressure or urethral pressure profilometry will influence the choice of surgical technique. Furthermore, there is little evidence to suggest that patients with more severe forms of stress urinary incontinence by urodynamic testing fare more poorly after the most commonly offered surgical treatment than those with less severe forms. There are certain sub-populations of women who appear to be at higher risk of voiding dysfunction following incontinence surgery, and urodynamic testing may aid in identifying this group. SUMMARY: It is not apparent that either abdominal leak point pressure measurement or urethral pressure profilometry can accurately predict which patients will achieve the best outcome of surgical treatment for stress urinary incontinence. Other parameters assessed during urodynamic evaluation might provide prognostic information regarding the risk of voiding dysfunction postoperatively and the possibility of persistent urge-related leakage following surgery, though not directly predict cure. A multi-institutional randomized study comparing the outcome between patients in whom treatment was determined with the urodynamic information known, compared with patients in whom this information was unknown would further enhance our understanding of the usefulness of urodynamics in the preoperative evaluation of women with stress urinary incontinence.     

Supine empty stress test as a predictor of low valsalva leak point pressure

Our objective was to determine whether a positive supine empty stress test is predictive of a low Valsalva leak point pressure (⩽60 cm of water). Evaluation was carried out on 179 patients with a history of genuine stress incontinence confirmed with urodynamic testing. All patients had a supine stress test performed after voiding. Residual urine determinations were all <100 cc. A vesical Valsalva leak point pressure determination (cough and strain) was performed during multichannel urodynamics with 150 cc in the bladder. Urethral profilometry was performed at maximum capacity. There was a statistically significant relationship between a low leak point pressure and a positive supine empty stress test (P < 0.000). The supine empty stress test had a sensitivity of 79% and a specificity of 62.5% for the detection of a low leak point pressure. The negative predictive value was high at 90%. For the age group 50 years and younger the negative predictive value was 95%. However, there was no significant relationship between a positive supine empty stress test and a low maximal urethral closure pressure. We conclude that the supine empty stress test is a useful screening test for a low leak point pressure but not a low urethral closure pressure. Its high negative predictive value is useful in excluding the presence of a low leak point pressure and may help the clinician to determine which patients with genuine stress incontinence need further assessment of the dynamic function of the urethral sphincter. Neurourol. Urodyn. 17:121–127, 1998. © 1998 Wiley-Liss, Inc.     

Urodynamic Assessment of Urethral Sphincter Function In Post-Prostatectomy Incontinence

Purpose

Direct measurement of maximum urethral pressure by urethral profilometry has been used widely to assess urethral sphincter function. We attempted to determine if there was any relationship between maximum urethral pressure, which is measured at the level of the membranous urethra, or extrinsic urethral sphincter function, and the amount of abdominal pressure needed to cause leakage (abdominal leak point pressure) in men with post-prostatectomy incontinence. We also examined the relationship between external sphincter function and continence or incontinence.

Materials and Methods

We retrospectively evaluated fluoro-urodynamics performed in 37 men with post-prostatectomy incontinence. Urodynamic study consisted of measurement of maximum urethral and abdominal leak point pressures, and assessment of extrinsic sphincter function by pressure measurements and radiographically.

Results

Data were analyzed on 27 patients for whom abdominal leak point and maximum urethral pressures were available. Mean maximum urethral pressure was 52.5 cm. water (range 20 to 165) and mean abdominal leak point pressure was 77.8 cm. water (range 27 to 132). Regression analysis was performed between maximum urethral and abdominal leak point pressures. A Pearson correlation coefficient of 0.13834 was calculated (p = 0.4914) indicating virtually no correlation between the 2 measurements in our sample. Extrinsic urethral sphincter was normal in all patients. Only 1 of 37 patients had no evidence of intrinsic sphincter deficiency, that is there was no urine leakage with increases in abdominal pressure and the patient was incontinent solely based on bladder dysfunction (detrusor instability).

Conclusions

Our study indicates that incontinence after prostatectomy due to an increase in abdominal pressure (stress incontinence) does not depend on extrinsic sphincter function and is not related to maximal urethral pressure. We conclude that post-prostatectomy incontinence due to sphincter dysfunction results from intrinsic sphincter deficiency. In our experience bladder dysfunction is rarely the sole cause of post-prostatectomy incontinence.     

女性盆底器官脱垂伴尿失禁患者的尿动力学特征

目的 探讨女性盆底器官脱垂伴尿失禁患者膀胱储尿期和排尿期的尿动力学参数变化. 方法对182例女性尿失禁和盆底器官脱垂患者进行尿动力学检查,其中尿失禁140例,尿失禁伴盆底器官脱垂42例.在统一标准下行尿动力学检查测定膀胱灌注量、排尿量、膀胱顺应性、最大尿流率、最大尿流率逼尿肌压、最小尿流率逼尿肌压、尿道阻力因子(URA)、膀胱梗阻指数(OBI)以及归-化逼尿肌收缩力,评价女性尿失禁患者盆底器官脱垂对膀胱储尿功能和排尿功能的影响. 结果 尿失禁组与尿失禁伴盆底器官脱垂组患者尿失禁病程[(58.1±75.4)与(41.9±55.4)个月]、膀胱灌注量[(295.3±95.8)与(276.5±80.8)ml]、膀胱顺应性[(77.7±122.1)与(51.5±61.9)ml/cm H2O]、最大尿流率[(15.8±12.5)与(14.7±13.9)ml/s]、最小尿流率逼尿肌压[(3.2±5.8)与(2.8±5.5)ml/cm H2O]、归-化逼尿肌收缩力[(7.5±12.8)与(8.2±13.8)cm H2O]相比差异均无统计学意义(P>0.05);而年龄[(58.7±12.2)与(67.1±8.3)岁]、排尿量[(269.2±145.2)与(248.9±135.1)ml]、最大尿流率逼尿肌压[(20.4±16.2)与(25.7±21.3)cm H2O]、URA[(11.3±9.5与(14.8±12.6)cm H2O]、OBI[(15.6±14.5)与(21.7±20.1)cm H2O]2组相比差异有统计学意义(P<0.05).结论高龄女性尿失禁患者更可能伴有盆底器官脱垂,而盆底器官脱垂对膀胱储尿功能无影响,但可影响排尿期相关参数,增加膀胱出口阻力和膀胱残余尿量.     

The supine stress test: a simple method to detect intrinsic urethral sphincter dysfunction.

PURPOSE: A new clinical test for intrinsic urethral sphincter dysfunction is proposed and compared to abdominal leak point pressure determination by video urodynamics. MATERIALS AND METHODS: Patients were prospectively included in the study if they had stress urinary incontinence symptoms and were to undergo video urodynamic testing. Patients with urinary tract infection, cystocele, rectocele and vaginal vault prolapse were excluded from study. A supine stress test using cough and Valsalva's maneuvers was performed after bladder filling to 200 ml. with sterile normal saline solution by gravity. Efflux of the bladder solution from the meatus coinciding with the cough or Valsalva maneuver indicated a positive clinical test. A video urodynamic study, including abdominal leak point pressure, was performed. Intrinsic urethral sphincter dysfunction was diagnosed if abdominal leak point pressure was less than 100 cm. water. Test indexes were calculated based on the results of the supine stress test and the abdominal leak point pressure measurements. RESULTS: Results were positive in 30 of 41 consecutive patients and negative in 11. Using abdominal leak point pressure measurement, the supine stress test had 93.5% sensitivity, 90.0% specificity, 96.7% positive predictive value and 81.8% negative predictive value for detecting intrinsic urethral sphincter dysfunction. CONCLUSIONS: The supine stress test is easy, quick and inexpensive, and a positive test is a reliable predictor of intrinsic urethral sphincter dysfunction. A negative test is highly correlated with the absence of intrinsic urethral sphincter dysfunction during video urodynamic testing. This test is more reliable in diagnosing intrinsic urethral sphincter dysfunction than other nonurodynamic tests reported in the literature. The supine stress test can be a useful supplement to cotton swab testing for urethral hypermobility in determining the appropriate management for stress urinary incontinence.