Systeme : URODYNAMIQUE Colonne d eau - Torricelli Objectif 5 :
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1 URODYNAMIQUE Colonne d eau - Torricelli Objectif 5 : connaître les principes de la cystomanométrie, savoir l enregistrer et l interpréter Systeme : Mesure manuelle de la Pression tous les 50 ml infusés Pression Vesicale Robinet 3 voies Volume CYSTOMETRIE à eau CYSTOMETRIE Catheters Capteurs de pression Remplissage vésical Pompe us Enregistrement de la pression vésicale, de la P. Abdo et du vol. Patient - vessie vide - Catheters en place et purgés - réponses OK en pression (élévation à la toux) - réponse OK - Information du patient sur le «besoin d uriner» - Patient relaxé Equipement - Vitesse remplissage 50 ml/min. - fenêtre analyse 1 min./div. - Amplitude pression 20 cmh 2 O/Div. urethre Préparation cystométrie : perfusion vessie rectum Capteurs de pression 1
2 Toilette périnéale Insertion cathéter vésical Insertion aiguille emg Remplissage vésical Insertion sonde rectale Connexion prolongateurs URODYNAMIQUE Principes Cystometrie : pression de base Volume l l l l l l l Volume 500 ml 600 Storage Phase CP RELAX Cystometrie : premier besoin Cystometrie : toux 2
3 Cystometrie : besoin pressant Cystometrie : Contraction non inhibée du Detrusor > 15 cmh 2 O Cystometrie : Hyperactivité Rectale Cystometrie : Urethre instable > 30 cmh 2 O Slow Waves Amplitude > 10 cmh 2 O Cystometrie : besoin urgent Cystometrie : Leak Point Autonomic Control Voluntary Contraction SD SD Leak 3
4 Cystometrie : Capacitée Maximum Cystometrie : Compliance du Detrusor P 2 P 1 Compliance = V 2 - V 1 P 2 - P 1 SD UR MC Leak SD UR MC V V ml Leak Resultats Cystométrie ICS Bladder & Urethral Function & Dysfunction Storage phase Evenements Volume Compliance cmh 2 O ml ml/cmh 2 O Pression base BP er besoin B. Pressant B. impérieux SD Urgency UR Capacité Max Cysto. CC Storage Phase DETRUSOR Normal (Stable) Normal Overactive (Unstable) Underactive Hyperreflexia Acontractile Areflexia Decentralised URETHRA Normal (Stable) Normal Incompetent Obstructive Urinary incontinence Mechanical (anatomy) Sphincter areflexia Overactive (function) Bladder neck Dyscoordination Dyssynergia Hyppereflexia BLADDER Normal Sensation Increased (Hypersensitive) Reduced (Hyposensitive) Absent Débimètrie Remplissage vessie Pression Techniques Urodynamiques (Methodes) Disque rotatif capteur de poids poids Eau CO 2 Pompe Gravitée Pompe capteur pression intégré Capteurs externes Micro capteur élec. With or w/o Lumen 5 cm Spacing Disposable : Dome Transducer Single or Dual Tip Cystomanométrie. V1/P1 Toux Fuite l l l l l l l Volume 400 ml 500 Temps B1 B2 B3 600 B4 Q ura DM RELAX Phase de remplissage CP Phase de Miction Phase de miction normal - Silence 4
5 Cystomanométrie de base : vessie normoactive Cystomanométrie de base : vessie hyperactive Test Positif A Test Positif C Test Positif B Cystomanométrie de base à 100ml/mn Uro - Video Test à l eau glacée : Cystomanométrie à 100ml/mn 10 sec/div 5
6 Cystometrie permictionnelle Parametres Vessie hyperactive Pre-Micturition Opening at Max. Flow Maximum Abdominal Maximum Intravesical Maximum Detrusor Maximum Flow Rate Opening 1 : Suppression influx inhibiteurs encéphaliques 2 : Prolifération fibres amyéliniques de type C Mécanismes de l hyperactivité suppression de l inhibition supra sacrée 1 P fibres C + 2 Nerf pelvien + activation des fibres amyéliniques de type C prolifération innervation sensitive Pharmacologie Hyperactivité GABA; CNS : dopamine, ac glutamique, Ach béta-adrénorécepteurs (béta 3 => relaxation) prostaglandines (récepteurs EP1) récepteurs tachykinine (NK1,NK2,NK3) récepteurs vanilloïdes (capsaïcine, RTX) bloqueurs K+, Ca++ (sélectivité ) sytèmes L Arginine / No / GMP / purinergique sérotonine (5 HT) [duloxétine, imipramine] périphérie : récepteurs muscariniques (M2,M3) atropine/ toltérodine/ oxybutinine/ probanthéline emepronium / darifénacine / trospium Gaba : baclofen P Neuro modulation S3 + Traitement hyperactivité Capsaïcine, rtx fibres C Toxine bot Pg Nerf pelvien + anticholinergique Beta bloqueur Anticalcique, K+ NK2 Rééducation 6
7 Traitement rétention Rééducation dorso N. hypogastrique lombaire P mimétiques P Nerf pelvien + Neuro modulation S3 Alpha bloquant Toxine botulique Autosondage Cas : vessie hyperactive neurogène vitesse remplissage : /min. faible Volume Vesical Contraction du Detrusor Immediate Compliance normale et augmentent pdt la miction 0 70 ml 7
8 Cas : Instabilité idiopathique Detrusor Cas : défaut de compliance Post Radiotherapie Vitesse remplissage /min. vitesse remplissage /min. Contraction du Detrusor après stimulation Compliance basse basse Compliance pression Detrusorienne élevée ~ 150 cmh 2 O ml ml Cas Dyssynergie Cas Obstruction Etude Pression-Débit Artefacts : diminution pression détrusor après toux La pression ne retourne pas à son niveau initial : Normal Obstructed Setup Incorrect ou Perte dans ligne ou capteur 8
9 Artefact : diminution pression détrusor Artefact : augmentation pression détrusor sans élévation pression vésicale Augmentation pression abdominale : Diminution pression rectale : - déplacement ballonet Rectal -selles sur le cathéter - fuite ds ballon rectal - cathéter obstrué rectal Artefact Activité pointes Artefact Artefact (phase miction) - Urine sur electrodes Urine sur Aiguille D emg Artefact augmentation P detrusor Catheter Abdominal Ejecté Apres forte Pression abdominale 9
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