间质性膀胱炎和下尿路综合征进展

1、间质性膀胱炎和下尿路综合征进展第1页，共54页，2022年，5月20日，14点11分，星期四There are five entities of lower urinary tract dysfunction (LUTD) underlined together for establishing clinical practice guidelines 1. LUTS/BPH2. overactive bladder (OAB)3. stress urinary incontinence/pelvic floor prolapse (SUI/POP)4. interstitial cystit

2、is (IC)5. geriatric incontinence (GI) 第2页，共54页，2022年，5月20日，14点11分，星期四SupplementAccording to the following description, two entities should be added into LUTD, i.e.6. detrusor underactivity (DN)7. sphincter overactivity (SO), formerly dysfunctional voiding (DV) 第3页，共54页，2022年，5月20日，14点11分，星期四IC and L

3、UTDAmong the five entities, functional disorder dominated in OAB, SUI, and GI, pathological or mechanical factors may dominate in BPH and IC. Functional disorder may also result from BPH and IC. We should always take attention to organic as well as functional elements in the diagnosis and treatment

4、of LUTD. 第4页，共54页，2022年，5月20日，14点11分，星期四IC and LUTDFunctional classification is very important to neurogenic or non-neurogenic LUTD.EAU lanched a classification system 2008 and proposed it for clinical practice. And we think its principle suited to non-neurogenic LUTD too. 第5页，共54页，2022年，5月20日，14点11

5、分，星期四第6页，共54页，2022年，5月20日，14点11分，星期四第7页，共54页，2022年，5月20日，14点11分，星期四The last two ones were marked as “sphincter only”, meaning the original lesion is subtle or unknown. Sphincter overactivity or underactivity in non-neurogenic LUTD, i.e., dysfunctional voiding (DV) or intrinsic sphincter deficiency （

6、ISD）, have the same meaning.第8页，共54页，2022年，5月20日，14点11分，星期四Old standard for interstitial cystitis (1988)第9页，共54页，2022年，5月20日，14点11分，星期四New name (PBS/IC）and its definition (confirmed in May 2007).PBS/IC would be diagnosed on the basis of chronic pelvic pain, pressure or discomfort perceived to be rel

7、ated to the urinary bladder accompanied by at least one other urinary symptoms like persistent urge tovoid or urinary frequency. Confusable diseases as the cause of the symptoms must be excluded. Further documentation and classification of PBS/IC might be performed according to findings at cystoscop

8、y with hydrodistention and morphological findings in bladder biopsies. 第10页，共54页，2022年，5月20日，14点11分，星期四Changes of name and meaning 第11页，共54页，2022年，5月20日，14点11分，星期四Diagnosis method The potassium chloride test, an intravesical challenge comparing the sensory nerve provocative ability of saline versus

9、potassium chloride using a 0.4M-KCl solution, has not gained acceptance as a diagnostic test for a variety of reasons.第12页，共54页，2022年，5月20日，14点11分，星期四Diagnosis method As the new century dawned, there was much confusion as to how to define this 100-year-old syndrome, and the need for a clinically use

10、ful, universally accepted way to characterize IC took to the forefront.第13页，共54页，2022年，5月20日，14点11分，星期四IC and LUTDIC is a diagnosis of exclusion, but exclusion of OAB is usually difficult to do.On one hand, because almost 60% of the patients regarded by experienced clinicians as suffering from IC/PB

11、S failed to meet the criteria, so it is likely that the prevalence of IC/PBS is much higher than traditionally believed.第14页，共54页，2022年，5月20日，14点11分，星期四IC and LUTDOn the other hand, some patients traditionally believed as IC may be or may be associated with OAB or DV .DV is a non-neurogenic sphincte

12、r overactivity (SO), in some way like detrusor-external sphincter dyssynergia in neurogenic patients.第15页，共54页，2022年，5月20日，14点11分，星期四IC and LUTD In the following urodynamics, our equipment was Urovision Janus V, from Life-tech International, Stafford, TX, 77477-3995, USA. Fax: 281-491-6600 第16页，共54页

13、，2022年，5月20日，14点11分，星期四IC, dysfunctional voiding and LUTD DV or SO had better to be confirmed by EMG and pressure-flow study. Although it says nothing about the storage phase in children, adult patients with DV usually complained of urinary frequency and urgency. 第17页，共54页，2022年，5月20日，14点11分，星期四When

14、 patients pass urine, the detrusor contracts and the sphincter should relax. 第18页，共54页，2022年，5月20日，14点11分，星期四When patients pass urine, the detrusor contracts and the sphincter should relax.第19页，共54页，2022年，5月20日，14点11分，星期四But in patients with DV, both detrusor and sphincter contract together.第20页，共54

15、页，2022年，5月20日，14点11分，星期四But in patients with DV, both detrusor and sphincter contract together, in this one she had detrusor underactivity too.第21页，共54页，2022年，5月20日，14点11分，星期四But in patients with DV, both detrusor and sphincter contract together，even in SUI patients.第22页，共54页，2022年，5月20日，14点11分，星期四M

16、echanism related to DV第23页，共54页，2022年，5月20日，14点11分，星期四Effective treatment of DV by GABA-ergic agonistExcitement of the GABA-ergic (such as baclofen) interneuron in the sacral spine by this transmitter induces relaxation of the external sphincter by way of efferent nerve fibrae of the pudendal nerve.

17、第24页，共54页，2022年，5月20日，14点11分，星期四Effective treatment of DV by GABA-ergic agonistWe have made a crossover trial to compare baclofen and control. （BJU Iinternational 2007, 100: 588592, and Nature Clinicalpracticeurology 2007, 4：580). The result was a good news for patients suffered from DV: Treatment w

18、ith baclofen improves dysfunctional voiding in women.第25页，共54页，2022年，5月20日，14点11分，星期四第26页，共54页，2022年，5月20日，14点11分，星期四第27页，共54页，2022年，5月20日，14点11分，星期四第28页，共54页，2022年，5月20日，14点11分，星期四The randomized crossover study design第29页，共54页，2022年，5月20日，14点11分，星期四A new urodynamic varible used in the evaluation of

19、 extent of harmony between detrusor and sphincterTo compare the extent of DV, the logarithmof the ratio of the electric potentials betweenbefore voiding and at Qmax was used and named as TL value. T:tense, L: loose.TL value= lg(Potentials before voiding/at Qmax)第30页，共54页，2022年，5月20日，14点11分，星期四A new

20、urodynamic varible: TL value The value should be positive in normal subjects with no DV and negative in subjects with DV, increasing when the DV improves or recovers to normal. 第31页，共54页，2022年，5月20日，14点11分，星期四A right and precise way to ingest the EMG signals of the anal sphincter Here EMG signals we

21、re ingested by transdermal perineal needle-guided wire electrodes, not by skin patch or concentric needle. It has been confirmed the good results and high sensitiveness in distinguishing dyssynergia (overactive) from synergia (normalactive) from more than 5000 cases we have performed so far. 第32页，共5

22、4页，2022年，5月20日，14点11分，星期四Baclofen improves dysfunctional voiding in womenThere were significantly fewer voids/24 h and a higher TL value in patients treated with baclofen than in those with placebo. Other variables that significantly improved with baclofen over placebo included increased Qmax and de

23、creased PdetQmax.第33页，共54页，2022年，5月20日，14点11分，星期四Baclofen improves dysfunctional voiding in women Baclofen at a dose of 10 mg, 3/d, is an effective and well-tolerated treatment option for patients who have DV. Baclofen decreases frequency and PdetQmax, and increases Qmax and TL value.第34页，共54页，2022年

24、，5月20日，14点11分，星期四Urodynamic investigations of a 55-year-old women with DV and a TL of 1.4, who complained of urinary frequency for 11 years第35页，共54页，2022年，5月20日，14点11分，星期四Her symptom improved significantly in the urodynamics, with a TL of 0.92, after 4 weeks oftreatment with baclofen.第36页，共54页，2022年

25、，5月20日，14点11分，星期四During UDS, we must make patients pass urine in sitting position, so position change is necessary.第37页，共54页，2022年，5月20日，14点11分，星期四During UDS, we must make patients pass urine in sitting position第38页，共54页，2022年，5月20日，14点11分，星期四This women pass urine in sitting position and showed DV.第

26、39页，共54页，2022年，5月20日，14点11分，星期四To women proposed as to be IC, the three therapies have the following meaning. “Criteria for the diagnosis of interstitial cystitis: E. Symptoms not significantly relieved by antimicrobial agents, anticholinergic drugs, or antispasmodics.”In another words, urinary trac

27、t infection, overactive bladder, dysfunctional voiding should be ruled out carefully, if comprehensive urodynamics is not available.第40页，共54页，2022年，5月20日，14点11分，星期四Roadmaps of interstitial cystitis and other lower urinary tract dysfunctionFrequency, urgency, and pain Urinary analysisAntimicrobial ag

28、entsPositive NegativeAnticholinergicsUrodynamicsUneffective OABDV or SOAntispasmodics (baclofen) Cystoscopy and hydrodistentionUneffectiveUneffective第41页，共54页，2022年，5月20日，14点11分，星期四Roadmaps of interstitial cystitis and other lower urinary tract dysfunction Three main elements in diagnosis of IC are

29、pain, frequency and positive finding of cystoscope with hydrodistention. At least two of them available are necessary to address IC. In our clinics, urodynamics was the first option for women suffering from frequency and urgency and pain with a negative urinalysis.第42页，共54页，2022年，5月20日，14点11分，星期四Tre

30、atment options for ICCurrent treatment modalities include: dietary control bladder retraining oral medication intravesical therapy hydrodistention neuromodulation surgical intervention psychological support 第43页，共54页，2022年，5月20日，14点11分，星期四Treatment options for ICDietary control: acidic foods, caffei

31、ne, alcohol, artificial sweetener and chocolate are common offending elements. 第44页，共54页，2022年，5月20日，14点11分，星期四Treatment options for ICBladder retraining: A protocol of progressive small increments in voiding time intervals第45页，共54页，2022年，5月20日，14点11分，星期四Treatment options for IC Oral medication: ant

32、idepressants, antihistamines (cimetidine, hydroxyzine) pentosan polysulfate (elmiron) sedatives and analgesics 第46页，共54页，2022年，5月20日，14点11分，星期四Treatment options for IC Intravesical therapy: DMSO heparin sulfate hyaluronic acid BCG capsaicin, RTX 第47页，共54页，2022年，5月20日，14点11分，星期四Treatment options for ICHydrodistentionNeuromodulation第48页，共54页，2022年，5月20日，14点11分，星期四Treatment options for ICSurgical interventionPsychological support第49页，共54页，2022年，5月20日，14点1