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O.A.B.

OVERACTIEVE BLAAS. O.A.B. 14 april 2010. Dr. A. Breugelmans Diensthoofd Urologie RZ Heilig Hart Leuven. Urineverlies – Talrijke mythes. MYTH: PREVENTION IS IMPOSSIBLE. MYTH: INDWELLING CATHETERS ARE THE BEST INTERVENTION FOR INTRACTABLE URINARY INCONTINENCE.

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O.A.B.

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  1. OVERACTIEVE BLAAS O.A.B. 14 april 2010 Dr. A. Breugelmans Diensthoofd Urologie RZ Heilig Hart Leuven

  2. Urineverlies – Talrijke mythes MYTH: PREVENTION IS IMPOSSIBLE MYTH: INDWELLING CATHETERS ARE THE BEST INTERVENTION FOR INTRACTABLE URINARY INCONTINENCE MYTH: THERE ARE NO EFFECTIVE TREATMENTS FOR URINARY INCONTINENCE-IT'S UNAVOIDABLE IN NURSING HOME RESIDENTS MYTH: THERE IS ONLY ONE TYPE OF URINARY INCONTINENCE MYTH: URINARY INCONTINENCE IS UNMANAGEABLE IN PEOPLE WITH DEMENTIA MYTH: COMPLETE CONTINENCE IS THE ONLY INDICATION OF SUCCESSFUL TREATMENT MYTH: URINARY INCONTINENCE FALLS UNDER THE PURVIEW OF PHYSICIANS; NURSES CAN'T DO MUCH TO HELP MYTH: URINARY INCONTINENCE IS INEVITABLE WITH AGE MYTH: OLDERADULTS DON'T MIND BEING INCONTINENT AND WEARING PADS

  3. Urineverlies – Evenveel oorzaken

  4. Urineverlies – Evenveel oorzaken • D elirium, dementia, deconditionering • I nfection, inflammation • A trophy of the vagina /urethra • P harmaceuticals, psychologic (depression) • E xcessive urine output (Cong.Heart Failure, diabetes) • R estricted mobility • S tool impaction, sacral nerve root pathology

  5. Urineverlies - Vormen • Inspanning • Urge • Mixed • Overloop • Continue • Centraal/Emotioneel (decorumverlies)

  6. Incontinentie / Residu • + residu : - BOOS - neurogene hypotonie (VSD, medicatie, L, hysterie) • - residu : - UWI sensorisch - atrofische vaginitis - fecale impactie - O.A.B.

  7. Inspanningsurineverlies • Zwakkesluiting(anatomisch / functioneel) • Bekkenbodemspieroefeningen • Alfa-adrenergica • (+/- anticholinergica) • TVT ea

  8. Theorie van Enhorning (druktransmissie)

  9. Integrale Theorie van Ulmsten

  10. Principe van de BH-suspensie Continente patiënt Incontinente patiënt

  11. Principe van de BH-suspensie

  12. Situering van de overactieve blaas

  13. Urgentie Incontinentie Overactieve blaas Incontinentie Urgentie • Frequency • 8 or more visits to the toilet per 24 hours • Nocturia • 2 or more visits to toilet during sleeping hours Stress Incontinentie Frequentie “symptom syndrome suggestive of lower urinary tract dysfunction” Nycturie Gemengde symptomen (Abrams et al. Neurourol Urodyn 21: 167-178, 2002); Milsom I, et al. BJU Int. 2001;87:760-766.

  14. 2 TYPES O.A.B. Patienten met urgentie, frequentieofnycturie: Patientenmet urgentie incontinentie: Normale patiënt “DROOG” “NAT”

  15. “STERK EN LUI ???” • Elderly: detrusorhyperactivity with impaired bladder contractility is common (DHIC) involuntary detrusor contractions, yet must strain to empty their bladders either incompletely or completely.

  16. ETIOLOGIE

  17. O.A.B. - Neurogene Theorie • Blaasvulling : sensorisch • motorisch Mictiefaze Blaasdruk Normale plasdrang Blaas vulling Blaas vulling Eerste plasgevoel Wein AJ, Rovner ES. Int J Fertil. 1999;44:56-66.

  18. Normale Mictie Controle Para (Voiding) Ortho (Filling) Adapted from Opsomer RJ., Lorge F., 1999

  19. Sympathisch Detrusorspier Centraal zenuwstelsel Parasympathisch Somatisch Externe sfincter Bekkenbodemspier Abrams P, Wein AJ. The Overactive Bladder—A Widespread and Treatable Condition. 1998. Bezenuwing van de lagere urinewegen

  20. During bladder filling distension results in afferent pelvic discharge; after synapse in pudendal nucleus efferent pudendal impulses produce contraction of external sphincter helping to maintain continence. Other efferent sympathetic fibres synapse in post ganglionic parasympathetic neuron, resulting in inhibition of detrusor contraction. • Afferentpelvicnerve discharges ascend in spinalcord, synapse in pontinemicturitioncentreDescendingefferentpathwayscauseInhibition of pudendalfiring - relaxation of sphincterInhibition of sypatheticfiring - opens bladder neckpelvicparasypatheticfiring - detrusorcontraction

  21. Neurotransmitters + receptoren Cholinerge receptoren Adrenerge receptoren Muscarine receptoren Nicotine receptoren (N) a- adrenerge receptoren b-adrenerge receptoren b1,b2,b3,..,bn a1,a2,a3,...,an M1, M2, M4, M5 M3

  22. Myogene Theorie Autonome Theorie

  23. UROTHEEL

  24. TRP-kanalen (Elaut, 2009) • Transient receptor potential channels • Ionenkanalen • Activatie: fysisch (T), mechanische stress, Chemisch (pH, osmol.) ZINTUIGEN VAN DE CEL

  25. PREVALENTIE en BELANG

  26. Prevalentie van O.A.B. EU StudyMilsom I et al. 2001 US NOBLE StudyStewart WF et al. 2003 45 40 40 35 Men Men 35 30 Women Women 30 25 25 20 Prevalence, % Prevalence, % 20 15 15 10 10 5 5 0 0 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75+ 18-24 25-34 35-44 45-54 55-64 65-74 75+ Age, years Age, years 1 op twaalf volwassenen lijdt aan de symptomen van overactieve blaas: dit is meer dan bij osteoporose of de ziekte van Alzheimer Epidemiological research done in 6 EU countries (France, Germany, Italy, Sweden, UK, Spain) Milsom I et al. BJU Int. 2001;87:760-766.Stewart WF et al. World J Urol. 2003;20:327-336.

  27. EUROPEAN UROLOGY Volume 57, issue 4, pages 551-734, April 2010Voiding DysfunctionA Comparison of the Frequencies of Medical Therapies for Overactive Bladder in Men and Women: Analysis of More Than 7.2 Million Aging PatientsBrian T. Helfand a, R. Mark Evans b, Kevin T. McVary a .

  28. Something You Haveto Learn to Live With * Something Few PeopleMy Age Have Ignored by the MedicalCommunity * A Result of theWay I Live * Hereditary,So It Can’t Be Helped A Sign of a More SeriousMedical Condition * Natural Partof Aging * Can’t Be Curedor Helped Total Not Really a Medical Condition * Women Men Not Worth Botheringa Doctor About * 0 10 20 30 40 50 60 70 80 90 Klachten ??? (Sickness or aging – Cicero 44AD) Urinary Problems Like Mine Are… Percentage of Subjects *P≤.05 vs men. Irwin DE et al. BJU Int. 2006;97:96-100.

  29. ? • Onwetend over mogelijke behandeling (“mythes”) • Beschaamd om erover te spreken • Aanpassing levensstijl ? • Kostprijs (verbandmateriaal, medicatie) • Geen totale genezing • Neveneffecten medicatie

  30. OAB en levenskwaliteit Beroepsmatig Sociaal Sexueel Impact vande OAB oplevenskwaliteit Huiselijk Fysisch Emotioneel

  31. Co-morbidities Associated With OABResults From the EPIC Study Men * 35 OAB cases (n = 502) 30 Controls (n = 502) 25 * 20 * 15 * 10 * * 5 0 Obesity Hypertension Depression Asthma Diabetes Chronic constipation Neurologicconditions Subjects, % Dyslipidemie * 30 Women 25 * OAB cases (n = 932) 20 * Controls (n = 932) 15 * * 10 * * 5 0 Obesity Hypertension Depression Asthma Diabetes Chronic constipation Neurologicconditions *P≤ 0.05 vs. controls (within gender). Irwin DE et al. Presented at ICS 2007

  32. DIAGNOSE

  33. Diagnose • Anamnese • KO • Urine • Mictiedagboek • Beeldvorming • Urodynamica

  34. Anamnese • Ziekten? • Medicatie? • Operatief? • Bevallingen? • Drinkgewoonte, plasgedrag • MOBILITEIT? • CONSTIPATIE?

  35. Sleutelvragen voor de patiënt • Hoe vaak gaat u in totaal naar het toilet gedurende een periode van 24 uur? – PLAST U VAAK ? • Hoe vaak staat u ‘s nachts op om naar het toilet te gaan? • Hoe vaak overdag voelt u een plotse en sterke drang om te plassen? • Komt u vaak te laat op het toilet? • Verliest u urine (HNP??) ? Gebruikt u inlegverbanden? • Hebt u regelmatig “blaasontstekingen” ? Abrams P, et al. Am J Manag Care. 2000;6(suppl):S580-S590. Chapple C., Pocket Reference to Overactive Bladder, 2007, Current Medicine Group

  36. OAB-V8 questionnaire

  37. Dag 1 • TijdstipGedronkenMoest u plassen? Ongewensturineverlies Plasdagboek – Volumedagboek – Mictiedagboek (3-7d)

  38. KlinischOnderzoek • Abdominaal • Neurologisch • Pelvisch (vrouw) • Genitaal/prostaat (man)

  39. … Nota: Bij de man … BPH BOO ischemie cholinerge denervatie detrusor-overactiviteit Zijn anticholinergica veilig bij BPH???

  40. Urine-analyse • Pyurie • Bacteriurie • Hematurie • Proteinurie • Glucosurie

  41. Beeldvorming • Echografie: blaaswanddikte, residu, RIP; ∆HUW?? • IVU, cystogram • CT-scan

  42. Specifiek urologisch onderzoek • Indien discordantie tussen anamnese, KO en eventuele proefbehandeling • Residubepaling • Uroflowmetrie • Cystometrie • Cystoscopie

  43. Urodynamischonderzoek

  44. Urodynamischonderzoek

  45. Urodynamischonderzoek

  46. BEHANDELING

  47. Behandeling • Gedrag • Anticholinergica • Topicavaginaal • Pelvischereëducatie

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