| BackgroundLower urinary tract dysfunction (low urinary tract dysfunction, LUTD) is a symptom including urine storage symptoms such as urinary frequency, urgency, nocturia, urge incontinence, stress incontinence, nocturnal enuresis and bladder discomfort, and voiding symptoms such as wait urination, urinary difficulty, urinary slow, interrupted urinary stream, urine without sense and other symptoms after dribbling. As the common findings of lower urinary tract dysfunction, stress urinary incontinence (SUI) and bladder outlet obstruction (BOO) are important factors affecting the quality of life in elderly patients. However, these symptoms alone is difficult to objectively reflect the extent of the disease, which also makes the diagnosis and treatment of certain blindness. Urodynamics is recognized as an important reliable means to evaluate lower urinary tract function.Stress urinary incontinence is a serious impact on the quality of life of women with the disease. International Continence Society defined that stress urinary incontinence is a symptem that urine flow out from the urethra of involuntary phenomenon when abdominal pressure (such as coughing, sneezing, action, fast walking, stair climbing, etc.) increasing. After puberty seen in women of all ages, and the rate of urinary incontinence occurringin from 15 to 64 years was approximately 10-55%, which accounted for 50% of stress urinary incontinence. Transurethral middle obturator tension-free sling surgery (TVT-O) is recognized as an effective means of treatment of SUI, but the tightness of the sling in the surgery is the key to affect the prognosis,otherwise the patient may obtain incontinence or voiding difficulties and other complications. Urodynamics is an important means to diagnose and understand the pathogenesis of SUI and also assessment tools for SUI severity and urinary bladder function in patients including bladder manometry, urethral closure pressure measurement, leak point pressure measurement, measurement of flow rate, video urodynamic assessment. Liquid bridge test (FBT), so-called bladder and urethra synchronous manometry, as a new means of urodynamic have begun to used in the clinical work, which includes continuous and fixed bladder and urethra synchronous manometry. Further, the ambulatory urodynamics monitoring(AUM) could suplly the condition for the patient to maintain their daily life, record the whole urinary bladder urodynamic parameters and timely detect the natural filling state. Records may be prolonged in patients with stress urinary leakage during daily activities change every time, and be more accurate to assess the stress incontinence in urodynamics. Therefore, the first part of this study was to compare the urodynamics performance and abdominal leak point pressure (LPP) in the women with stress urinary incontinence and normal women, the aim is to understand the value of" liquid bridge test " joint with LPP to diagnosis of urinary tract function, and gave the primary guidance for TVT-O surgery. While we gave some female patients with SUI ICI-Q-SF questionnaire, conventional Cystometry and different urodynamics, to understand the urodynamics differences in SUI patients between AUM and CUM, to provide a reference for the clinical application of AUM.Urodynamics is an evaluation means for the bladder, urethra function including objective means such as uroflowmetry, cystometry, urethral pressure measurement and other technical parameters. Qmax is especially regarded as an important parameter for diagnosis of bladder outlet obstruction. Benign prostatic hyperplasia (BPH) is a common disease in older men, and there are a 50% presence of histologically benign prostatic hyperplasia in men over age 50, over 75% in 70 years, 90% in 80 years, which seriously affected the quality of life of patients. Currently, cystometry is the gold standard for diagnosing BOO in the patients with BPH, and as a relatively noninvasive means the maximum urinary flow rate (Qmax, ml/s) is recognized as a more reliable indicator to screen BOO. Urine flow acceleration is a new parameter derived from flow rate curve which is measured from the beginning of urination into the peak urinary flow rate in a period of time. UFA is the increased urine flow velocity vector, which can reflect the urine flow increasing. The second part of this study is to introduce how to caculate the UFA, and to study the clinical value of UFA to diagnosing BOO in patients with BPH.ObjectivePart 11, By comparison with the urodynamic results of continuous FBT in women patients with SUI and normal women, the aim of this study is to explore the application value of bladder and urethra synchronous manometry (BUSM) so-called FBT in the assessment of female stress urinary incontinence.2, By comparison with the urodynamic results of fixed FBT in women patients with SUI and normal women, the aim is to understand the value of" liquid bridge test " joint with LPP to diagnosis of urinary tract function, and gave the primary guidance for TVT-O surgery.3, By comparison with the urodynamic results of CUM and AUM in female patients with SUI and the ICI-Q-SF questionnaire results, the aim is to understand the urodynamics differences in SUI patients between AUM and CUM, to provide a reference for the clinical application of AUM.4, By recording the normal urine flow curve of 24 hours in young men, including urine output, urine flow rate, bladder residual urine volume (postvoid residual volume, PRV) and calculating the urine flow acceleration, the aim is to explore the physiological variation of UFA.5, By detecting the changes of vital signs, urine flow curve parameters and blood concentration of healthy young men before and after oral tamsulosin,understand the impact on the health of young men tamsulosin flow rate of each parameter, the aim is to the relationship between UFA and a- receptor in bladder and urethra.6, By Comparing the specificity, sensitivity and diagnostic value of Kappa of UFA and Qmax to predict BOO in patients with BPH, the aim is to evaluate the clinical value of UFA.Materials and MethodsPart 1 The application study of fluid bridge test and ambulatory urodynamics monitoring for diagnosing female stress urinary incontinenceProtocal 1:We selected some cases diagnosed as stress urinary incontinence(SUI) in urodynamic examination center of our hospital.The following is the groups:35 females (49.5 ± 8.6) years old with SUI as the test group, and normal female 30 cases (49.6±13.6) years of age as a control group. Using MMS urodynamic instrument approach based on urodynamic International Continence Society prescribed for all patients for routine urodynamic bladder and urethra synchronous and continuous load (liquid bridge experiments). Specific methods are:patients into three chambers on the 10th of bladder and rectal abdominal piezometric piezometer. Take semi-sitting position, conventional static urethral pressure measurements to determine the position of the maximum urethral pressure and fixed piezometric to rate 50ml/min perfusion bladder and urethral perfusion 2ml/min speed, simultaneous measurement of filling of the bladder pressure and filling of the urethral closure pressure (filling urethral closure pressure, UCPfill), while filling to 200ml, the patient is asked to synchronize the Valsalva maneuver increases abdominal pressure and urethral pressure observed changes in the bladder, urethral closure pressure recorded at least two times during the Valsalva maneuver, and then averaged (Urethral closure pressure, UCP) and calculate the conductivity abdominal pressure (Pressure-to-transmission ratio, PTR); urethral closure pressure (Voiding urethral closure during normal filling to urinate urinate naturally continue to observe the changes in bladder pressure and urethral pressure, maximum flow rate when recording pressure, UCPvoid). Application of SPSS 17.0 software for statistical analysis, quantitative data are mean ± standard deviation, qualitative data using a percentage. Statistical Methods for two independent samples t test to P<0.05 was considered statistically significant.Protocal 2:We selected some cases diagnosed clinicaly as stress urinary incontinence(SUI) in urodynamic examination center of our hospital.The following is the groups:50 female patients with clinical stress urinary incontinence as the test group,31-81 years old, mean (45 ± 9)years, the symptoms of urinary incontinence last 2 months to 36 years; and other 35 female patients without lower urinary tract symptoms as a control group,27-75 years old, mean 43 ± 7 years. The measurement was according to the standard methods urodynamic by International Continence Society recommend, and at the same time pointing the bladder and urethra synchronous manometry (liquid bridge test) and LPP measurement checks. During free flow rate, pressure, flow rate, LPP measurement, measuring the static pressure of the urethra, bladder filling the patient to urinate in a normal state, so that the load pressure of the bladder catheter side hole 10F located in the three chambers of the bladder, and the urethra pressure side holes are located at the urethral sphincter, urethral pressure changes according to the highest value in the steady and pulled back as manometry catheter sites. Then ask the patient to cough or Vasalva actions carried increased abdominal pressure, and the simultaneous determination of changes in bladder pressure and urethral pressure, bladder pressure is increased magnitude greater than the magnitude of the urethral pressure is increased as positive, negative and vice versa. Calculated at the time of the bladder and urethra, respectively, increased abdominal pressure increases the pressure difference between the (△P). Liquid bridge test positive rate and the difference between the two groups were compared in patients with fluid bridge test positive urinary bladder pressure increased value and increased pressure value (AP) differences, and compare other urodynamic parameters. Statistical analysis was performed using SPSS 17.0 software, measurement data with the mean±standard deviation between the two groups were compared using LSD-t test was used to compare the rate of chi-square test. P<0.05 was considered statistically significant.Protocal 3:We selected the following patients in the urodynamic center of our hospital center:30 female patients with SUI symptoms (with or without UUI). Their age were from 32 to 63 years old (mean 49.4±9.449 year). The symptoms last from 1 to 9 years(mean 4.7±2.784 year). All patients were firstly under international advisory committee Incontinence Incontinence Questionnaire Short Form (ICI-Q-SF) questionnaire, and we got the ICI-Q-SF score by adding the result(3,4,5 scores) from ICI-Q-SF questionnaire, the scores ranges from 0 to 21 points, the higher the score indicates more severe incontinence. We will score range is divided into three levels of light in weight. That score of 0-7 points were mild incontinence,8 to 14 minutes were moderate incontinence,15 to 21 minutes by severe incontinence. Then conventional urodynamics and dynamic urodynamics. All patients were using the 7th three-chamber air bladder pressure air pipe and the 7th rectal manometry tube and pad use in the inspection process. Patients with normal drinking water, to be patient urinate again returned to the examination room, the location and use of measuring urinary flow rate signal quality, inspection and calibration of the catheter and the like. SUI during examination, the patient is asked to reproduce easily lead to leakage of urine daily life activities, such as coughing, laughing, walking, lifting weights, up and down stairs, and while monitoring and recording pressure changes in patients with bladder and urethra, and its parameters measured were compared. The experimental results with the number of cases and the mean ± standard deviation, the results was analysed by SPSS 17.0 software, Fisher exact test and paired t test was performed, and P<0.05 was considered statistically significant.Part 2 The application study of urine flow acceleration for evaluating the function of bladder and urethraProtocal 1:We selected 12 subjects without other diseases and disorders of urination (age 22-26 years, mean 24.8 ±1.2 years), and recorded all the flow rate over the entire 24-hour monitoring of each urination, urinary records flow curve shape, urine output, residual urine volume, maximum flow rate, urinary flow acceleration. And 18:00-06:00 as the night time as the rest of the day, divided into two time periods were compared. The mean urinary flow acceleration was calculated. Measurement data were presented as mean ± standard deviation, t-test to compare before and after medication flow rate parameters and vital signs to P<0.05 was considered statistically significant.Protocal 2:We selected 8 subjects from the above without voiding dysfunction in young men (aged 23-26 years, mean 25 ± 1.2 years) in front of tamsulosin capsules orally twice freely flow rate measurement parameters and vital signs monitoring, each time with a B-Determination of residual urine; conduct flow rate measurement parameters and vital signs monitored approximately every two hours within 24 hours after oral administration of Harold capsules, each time with a utral-sound measurment of residual urine volume. Each one hour after taking the medication and 10,12,16,24,36,48,72 hour plasma concentrations were measured separately within 8 hours. Measurement and analysis of the results, before and after medication urinary parameters, vital signs, in particular changes in urine flow acceleration; depicts the plasma concentration of tamsulosin and scatterplots about the existence of the plasma concentration of urinary parameters affected. Measurement data were presented as mean ± standard deviation, t-test to compare before and after medication flow rate parameters and vital signs to P<0.05 was considered statistically significant.Protocal 3:A retrospective analysis was performed in 50 cases with BPH evaluated by Laborie urodynamic instrument in our hospital, while we exclude th neurogenic bladder factors for prostate cancer, diabetes, lumbosacral disease, the exclusion of other factors that can affect urine flow change. And simultaneously we selected other 50 patients in the same period with no prostatic hyperplasia as the control group. Two groups of patients were compared urine flow acceleration and acceleration of benign prostatic hyperplasia group mean urinary flow initially diagnosed as a reference value. The maximum flow rate prescribed ICS<10ml/s was as a reminder of bladder outlet obstruction reference. Further analysis of the measured urine flow acceleration, maximum flow rate, and pressure - the results of flow rate. The preliminary determination urinary acceleration acceleration and maximum urinary flow rate if there is bladder outlet obstruction, and the pressure-flow rate P-Q chart tips obstruction region as the gold standard for sensitivity and specificity of the former two are compared. SPSS 17.0 statistical software was used to evaluate the correlation between the variables of each detected among the indicators used to compare different groups of samples t test, P<0.05 considered statistically significant. At last we calculated the sensitivity, the specificity and the kappa values of UFA and Qmax diagnosing BOO.ResultsPart 1 The application study of fluid bridge test and ambulatory urodynamics monitoring for diagnosing female stress urinary incontinenceProtocal1:The bladder urethral pressure of the SUI group and the control group during the filling is higher than the pressure, urethral closure pressure is positive, and the front end of the filling stage and filling UCPfill did not change significantly (P> 0.05); SUI group, but significantly lower than the control group UCPfill [(53.8 ± 13.5) cmH2O vs (82.8±16.8) cmH2O, (51.1±13.5) cmH2O vs (80.1±17.1) cmH2O, (P <0.05)]; when patients Valsalva maneuver, SUI group had urinary leakage, UCP and PTR each (-1.6±2.3) cmH2O and (0.41±0.11); the control group had no urine leakage, UCP and PTR each (44.3±18) cmH20 and (0.63±0.16), the difference between the two groups were statistically significance (P<0.05). Voiding SUI group and the control group voiding bladder pressure, urethral pressure synchronous reduced urethral closure pressure is negative. There was no significant difference UCPvoid between the two groups (P>0.05).Protocal 2:There were 3 patients with stress/urge incontinence in patients with clinically diagnosis of stress urinary incontinence, and one case diagnosis of mixed incontinence. There were 46 cases were diagnosed as genuine stress incontinence, and 44 cases (44/50) showed liquid bridge test positive,, in which 11 cases of type Ⅰ, type Ⅱ in 12 cases, Ⅱ/Ⅲ type in 9 cases, Ⅲ in 12 cases. Liquid Bridge test positive control group,2 patients (2/35). By chi-square test, we calculated X2 = 56.14, (P<0.05). There liquid bridge test positive rate between the two groups significantly different (44/50vs.2/35) (P<0.05). Among the stress urinary incontinence in patients with type Ⅰ △P is (11.0±2.6) cmH20 (1 group), type Ⅱ AP (19.6±4.3) cmH2O (2 groups), Ⅱ/Ⅲ type AP (35.2±9.1) cmH20 (group 3), Ⅲ type AP (49.7±9.3) cmH2O (4 groups). There was no significant difference between the first group and other two groups (P>0.05). There were significantly different between other groups except the first group(P<0.01), which showed an increasing trend.Protocal 3:We selected 30 patients with SUI symptoms, and 21 patients performed with CUM and AUM were diagnosed SUI,6 patients diagnosed with SUI by AUM but CUM showed a negative positive result.There are three cases of patients diagnosed with SUI two checks were not positive results. The result obtained by Fisher exact test showed the detection rate of AUM of SUI was significantly higher than CUM(P<0.05). Meanwhile,30 cases of female patients with SUI symptoms in three cases while AUM diagnosed with CUM DO positive results. There are eight patients diagnosed DO AUM CUM diagnosed positive results and negative results, with 0 patients diagnosed DO AUM negative results the CUM diagnosed positive results.19 patients were not diagnosed of DO positive. The DO diagnosing rate by AUM was significantly higher than that of CUM(P<0.05).Part 2 The application study of urine flow acceleration for evaluating the function of bladder and urethraProtocal 1:We deleted the urine flow curve of less than 150ml of urine each time. During the day of collection of statistical curves and the corresponding urine flow urine output, maximum urinary flow rate, urinary flow acceleration, residual urine volume 28 cases; night to collect a total of 25 cases. Two time periods voided volume, maximum flow rate, urinary flow acceleration, residual urine volume no difference: (342±125) VS.(377±154) ml; (21.6±4.3) VS. (19.8±3.9) ml/s; (3.05±1.12) VS. (2.98 ±0.95) ml/s2;. (15±4.5) VS. (16±3.6) ml.. All-day computing urine flow acceleration (2.13-8.01) ml/s2, average (3.10±0.96) ml/s2. Urine flow curve shape were diverse, and the UFA all the day was stable.Protocal 2:The urine flow acceleration reached a peak at about 3-6 hours after taking the drug, was significant different from that before taking the drug (P<0.05) (3.82±1.08) VS. (4.49±0.86).However, the average flow rate, maximum flow rate,voiding time, voided volume and bladder residual urine volume, vital signs had no significant difference (P>0.05).Protocal 3:There was no difference in age between the two groups (58±12.5 VS.59±13.0 years, P>0.05). Analysis of urodynamics data presented in table 1 revealed that the subjects with BOO had significantly smaller maximum flow rate (8.50±1.05 vs.13.00±3.35 mL/s), and lower urine flow acceleration (2.05±0.85 vs. 4.60±1.25ml/s2, P<0.001) than those without. There were significant differences in the prostate volume, post void residual and detrusor pressure at Qmax between two groups (28.6±9.8VS.24.2±7.6mL,60.4±1.4VS.21.3±2.5mL and 56.6±8.3 VS.21.7±6.1 cmH20, P<0.05). We tentatively used the mean of UFA as standard. According to the criteria (UFA<2.05 mL/s2, Qmax<10mL/s), the sensitivity and specificity of UFA and Qmax in diagnosing BOO were 88%,75% vs.81%,63% respectively.Conclusions1, The fluid bridge test is an effective method to evaluat the function of urethra, which can be used as a diagnostic tool for female stress urinary incontinence.2, There was high positive rate of the fluid bridge test in women with SUI. The FBT can be a useful dynamics method to diagnosing SUI in women and to predicting the urethral disfunction. Besides, △P may be a predictor for typing SUI.3, AUM was easy to monitoring SUI than the CUM. For patients with clinical symptoms of SUI, AUM can reduce the rate of misdiagnosis of DO than CUM.4, Urine flow aceleration is very stable during the day and night. There are varied shapes urinary flow curves in healthy young men.5, There is a close connection between the uroflow and blood concentration of tamsulosin. UFA can reflect the function of bladder and urethra.6, UFA can help make clear the change of detrutor in patients with BPH and UFA is a useful urodynamic parameter in diagnosing BOO in patients with BPH. |
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