Evaluation of Female Lower Urinary Tract Symptoms (F – LUTS)

1. Evaluation of Female Lower Urinary Tract Symptoms (F – LUTS) Dr Ismaiel Abu Mahfouz

2. Changing life style

4. QoL

5. Denial

6. Impact on quality of Life (QoL)

7. Female - LUTS Causes Terminology Clinical assessment Investigations

8. F- LUTS Causes

9. Causes of Female LUTS Urinary tract infection Renal stones Various types of urinary incontinence Urethral stricture Urological cancer

10. Types of urinary incontinence Urodynamic Stress Incontinence (USI) Detrusor Overactivity Incontinence (DOI) Mixed Urodynamic Incontinence (MUI) Overflow incontinence Urogenital fistulae Congenital (ectopic ureter) Urethral diverticulum UTI Medications Functional (e.g. immobility)

11. F-LUTS Terminology

12. Storage symptoms • Urinary incontinence The complaint of any involuntary leakage of urine • Urgency Sudden compelling desire to pass urine, which is difficult to defer • Increased daytime frequency The complaint by the patient that he/she voids too often by day • Nocturia The complaint that the patient has to wake up at night one or more times to void • Nocturnal enuresis The complaint of loss of urine occurring during sleep

13. Storage symptoms • Urge urinary incontinence (UUI) Involuntary leakage accompanied by or immediately preceded by urgency • Stress urinary incontinence (SUI) Observation of involuntary leakage from the urethra, synchronous with exertion / effort, sneezing or coughing • Mixed urinary incontinence (MUI) Involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing

14. Storage symptoms • Continuous urinary incontinence Complaint of continuous leakage day and night • Other types of incontinence • Incontinence intercourse • Postural incontinence • Giggle incontinence

15. Overactive Bladder (OAB) Urgency, with or without urge incontinence, usually with frequency and nocturia Also known as: • Overactive bladder syndrome • Urge syndrome • Urgency-frequency syndrome

17. Voiding symptoms • Slow stream Perception of reduced urine flow, usually compared to previous performance or in comparison to others • Intermittent stream (intermittency) Describes urine flow which stops and starts, on one or more occasions, during micturition • Hesitancy Difficulty in initiating micturition resulting in a delay in the onset of voiding after the individual is ready to pass urine • Straining to void Describes the muscular effort used to initiate, maintain or improve the urinary stream

18. Post-micturition symptoms Experienced immediately after micturition • Feeling of incomplete emptying Self-explanatory term for a feeling experienced by the individual after passing urine • Post-micturition dribble Describes the involuntary loss of urine immediately after finishing passing urine, usually after rising from the toilet

19. F- LUTSClinical assessment

20. Clinical evaluation

21. History Details of the presenting symptoms Symptoms: characterized and quantified When more than one symptom is present, which is the most bothersome Bladder diary For incontinence, a pad test

22. Past medical history Known neurologic diseases MS, spinal cord injury, lumbar disk prolapse, CVA Parkinson’s If no history of neurologic diseases, ask about: Double vision, muscular weakness, paralysis or poor coordination, tremor, numbness History of vaginal surgery Abdomino-perineal resection, radical hysterectomy Radiotherapy Small capacity, low compliance, radiation cystitis

23. Medication history Medications may cause LUTS Alpha-adrenergic agonists: Urethral obstruction and urinary retention Alpha adrenergic antagonists: SUI Tricyclic anti-depressants: Bladder outlet obstruction Narcotic analgesics and anti-histamines: Impaired detrusor contractility that can urinary retention Parasympathomimetics ( bethanechol ): Involuntary detrusor contractions, bladder pain

24. Abdominal and Pelvic examination

25. Physical examination Detecting anatomic and neurologic abnormalities that contribute to LUTS Neurological examination: Gait, abnormal speech, facial asymmetry…… Abdomen Masses, hernias, distended bladder Sacral innervation (S2, S3, S4) Anal sphincter tone, genital sensation

26. Physical examination Vaginal examination Atrophy Urethral caruncle Urethral mucosal prolapse POP

27. Imaging

28. F-LUTS Investigations

29. Investigations

30. Basic investigations

31. Urine test

32. The Bladder Diary Daytime urinary frequency Nocturnal frequency/nocturia Twenty-four-hour frequency Twenty-four-hour urine production Maximum voided volume Average voided volume Median functional bladder Polyuria: (> 40 ml/kg in during 24 hr or 2.8 L) Nocturnal urine volume Nocturnal polyuria (>30% of 24 H urine production)

34. The Pad Test • Objective assessment of urinary incontinence The International Continence Society (ICS) 1 Hour Standardised Test • Pre-weigh pad • Drink 500 mls of fluids • Rest 15 minutes • Moderate exercise 30 minutes • 15 minutes provocative exercises Results • Positive test : >2g increase in pad weight • Severe incontinence: >10g increase

35. Advanced investigations • Urodynamic studies (UDS) • Conventional UDS • Videocystourethrography (VCU) • Ambulatory Urodynamic Monitoring (AUM) • Surface electromyography (EMG) • Urethral Function tests • Imaging studies Ultrasound scan Contrast studies MRI • Cystourethroscopy

36. Urodynamics Studies (UDS) Why?

37. Urodynamics Studies (UDS) • Free flow study • Filling Cystometry • Voiding cystometry

38. Uroflowmetry • Simple • Non-invasive • A Record of voided volume and flow rate The definition of “Normal study” • Peak flow rate >15ml/sec • Voided volume >150ml • PVRV <100 mls

39. Free flow study Straining Normal Detrusor under-activity

40. Filling Cystometry • Measurement of the detrusor pressure / volume relationship • Assess: Bladder sensations, compliance, capacity • Filling medium: saline, contrast at room temperature • Filling rate: ? 20 ml/min • Supine, sitting or standing positions • Short, flexible, small (8F) catheters • Sealed system, no leak, no air bubbles

41. Urodynamics

42. Urodynamics

43. Detrusor over-activity incontinence (DOI) Cough DO

44. Voiding cystometry(Pressure flow studies) The relationship between detrusor pressure and flow rate • Obstruction High detrusor pressure (>50 cmH20) Poor flow (<15 mls/sec) • Under-active detrusor function Low detrusor pressure (<20 cmH20) Poor flow (<15 mls/sec)

45. Urodynamic diagnoses Detrusor overactivity (DO) A urodynamic observation characterised by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked Detrusor overactivity incontinence (DOI) DO associated with urine leakage Urodynamic stress incontinence (USI) Involuntary leakage of urine during increased abdominal pressure, in the absence of a detrusor contraction Mixed urodynamic incontinence DO and /or DOI + USI

46. Vediocystourethrography (VCU)

47. VCU: Advantages, Disadvantages Advantages: Simultaneous visualisation of the lower urinary tract Trabiculation, Diverticulae, Filling defects VU Reflux VCU Position of bladder neck in relation to pubic symphysis Bladder neck closure during rest and stress Fistuale (Vesico-vaginal / uterine, urethro-vaginal ) Vesico-ureteric reflux Disadvantages: X-ray exposure Expensive Allergic reaction to contrast media

48. Ureteric reflux Trabeculation Diverticulae

49. Ambulatory Urodynamics Monitoring(AUM)

50. Ambulatory urodynamic monitoring (AUM) Indications • Failure to reproduce LUTS on UDS • No response to anti-muscarenics (Question the Dx) • Failed repeated incontinence operations • Neurogenic dysfunction AUM • More accurate assessment of LUTS • Conventional UDS more sensitive in the diagnosis of USI • AUM more sensitive in diagnosing DO