Bladder Outlet Obstruction in Women

1. Bladder Outlet Obstructionin Women Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

2. Causes of Obstructive LUTS in Women • Bladder hypersensitivity • Poor relaxation of pelvic floor muscles • Spastic urethral sphincter • Bladder neck dysfunction • Urethral stricture • External compression • Prolapse of uterus

3. Bladder outlet obstruction in women • Diagnosis of BOO in women is often overlooked • Incidence of BOO is about 2.7 – 23% • Anatomical and functional cause of BOO contributed equally • Detrusor instability coexists with BOO • Patients may present with storage LUTS

4. Criteria for Female BOO • Massey & Abrams: PdetQmax>50 cm water and Qmax <12 ml/s • Axelrod & Blaivas: sustained PdetQmax >20 cm water and Qmax <12 ml/s • Chassagne et al: PdetQmax>20 cm water and Qmax <15 ml/s • Nitti: VUDS proven obstructed outlet, high pressure, low flow, large residuum

5. Incidence of BOO in Women Approximately in 2.7% to 8% in the women with LUTS undergoing urodynamics • Chassagne （1998）：35/159（22%）with Qmax <15ml/s and Pdet.Qmax >20cmH2O • Nitti（1999）：76/331（23%）with radiographic urethral narrowing and reduced flow • Groutz（2000）：38/587（6.5%） with Qmax <12ml/s and Pdet.Qmax >20cmH2O

6. Etiologies of BOO in Women • Previous anti-incontinence surgery 20% • Severe genital prolapse 16% • Severe prolapse and surgery 4% • Urethral stricture or narrowing 18% • Primary bladder neck obstruction 6% • Urethral diverticulum 6% • Learned voiding dysfunction 4% • Detrusor external sphincter dyssynergia 4% • Idiopathic 22%

7. Bladder Neck Dysfunction • No definite scarring tissue • Persistent narrowing of bladder neck during voiding • Trabeculation of bladder wall • Bilateral hydronephrosis may occur • Alpha-blocker or TUI-BN is effective • Recurrence of obstruction is possible

8. Bladder neck dysfunction in woman

9. Urethral stricture in woman • Definite urethral scarring can be found in cystourethroscopy or urethrogram • History of indwelling Foley catheter or transurethral surgery • Obstructive type low flow rate • Coordinated urethral sphincter EMG during voiding phase • Relief of obstructive symptom after urethral dilatation • Medication are not always effective

10. Urethral Stricture

11. Dysfunctional voiding in woman • Spastic urethral sphincter as etiology • Learned habit? • May present with frequency urgency dysuria and/or urge incontinence • Cystourethrography revealed spinning top appearance • Patient may have bilateral VU reflux or recurrent UTI

12. Spastic urethral sphincter (Dysfunctional voiding)

13. External compression of urethra • Infrequent cause of bladder outlet obstruction in women • Prolapse of uterus or uterine tumor compression of the urethra and bladder neck, imperforated hymen • May present with severe dysuria and large residual urine or urine retention • Physical examination or cystoscopy may aid in diagnosis

14. Iatrogenic bladder outlet obstruction • Anti-incontinence surgery or anterior colporrhaphy – transvaginal or transabdominal surgery may occur • Severe frequency, urgency, and dysuria developed after anti-incontinence surgery • A low flow rate with large residual urine • Elevated bladder neck and angulated urethrovesical angle

15. Iatrogenic urethral obstruction

16. Detrusor instability developed after Bladder neck suspension

17. Uterine prolapse and Cystocele • Gr 5 cystocele and uterine prolapse cause angulation of urethrovesical angle • Patient always uses manual reduction of bladder to void • Large residual urine and low flow rate • May mask intrinsic sphincter deficiency during leak point pressure measurement

18. Cystocele and Uterine Prolapse

19. Uterine prolapse and BOO

20. Reduction of cystocele relieves BOO

21. Obstructive uropathy in prolapse

22. Urethral meatal stenosis

23. Comparison of Qmax in BOO and non-BOO women

24. Comparison of detrusor pressure in BOO and non-BOO women

25. Nomogram for Female BOO

26. Blaivas BOO nomogram

27. Medical Treatment for Female BOO • Skeletal muscle relaxant – diazepam, baclofen, dantrolene, calcium blocker • Alpha-adrenergic blocker – dibenylene, terazosin, doxazosin, tamsulosin • Nitric oxide donor- nitroglycerine, isosorbid mononitrate • Estrogen • Botulinum A toxin

28. Surgical Treatment for Female BOO • Transurethral incision of bladder neck • Urethral dilatation • Transurethral sphincterotomy • Meatotomy • Transvaginal urethrolysis

29. Isolated urethral sphincter obstruction in detrusor areflexia

30. Botulinum A toxin sphincter injection • Botulinum A toxin is an inhibitor of acetylcholine release at the presynaptic neuromuscular junction • Inhibition of acetylcholine release results in regional decreased muscle contractility at the injection site • This chemical devervation is a reversible process, axons resprout in about 3-6 months

31. Clinical application of botulinum A toxin in voiding dysfunction • Botulinum A toxin 20-80 units successfully treated 11 SCI & DESD (Dykstra et al 1988) • In 21 of 24 SCI & DESD, BTX-A toxin 100 IU reduced residual urine and MUCP (Schurch 1996) • Transperineal injection of BTX-A in 6 SCI improved voiding function (Schurch et al 1997) • Improved bladder capacity and decreased maximal detrusor pressure after BTX-A in 5 SCI (Gallien et al 1998) • Relief of voiding dysfunction due to prostatitis in 4 men (Maria et al 1998) • Effective in treating DESD (12), pelvic floor spasticity (8), and acontractile detrusor (1) by BTX-A 80-100 IU (Michael et al 2001)

32. Botulinum A toxin therapy • 100 units (1vial) is diluted to 2ml • 50 units will be used in the first trial, 4 equivalent aliquot are injected via cystoscopy guide in men and around the urethra in women • Complete cardiorespiratory monitoring in OR • Foley catheter is indwelled for 1 day • Report adverse effect (AD, hematuria, UTI)

33. Botulinum A toxin injection in women

34. Botulinum A toxin injection in Spinal cord injured woman with DESD

35. Reduction of MUCP after Botulinum A toxin injection

36. Urethral Injection of Botulinum A toxin for Female BOO

37. Transurethral incision of urethral sphincter • Total incontinence after sphincterotomy • Indicated in quadriplegia women with adequate detrusor contractility and DESD, recurrent UTI or upper tract deterioration • Crede maneuver may be indicated • Irreversible procedure, should be performed with adequate informed consent • Botulinum toxin injection maybe another alternative

38. Detrusor instability and Female BOO • In women with frequency urgency and urge incontinence, detrusor instability may be due to BOO • Idiopathic DI may be occult neuropathy in young women, such as multiple sclerosis • Dysfunctional voiding should also be considered

39. Dysfunctional voiding and bilateral VUR in a woman with incontinence

40. Screening of BOO in Women with LUTS • Patient with urge incontinence after anti-incontinence surgery • Urge incontinence associated with dysuria, refractory to medication • A low maximal flow rate with plateau flow pattern,nor respond to medication • Elderly women with frequency & dysuria • Previous catherization and LUTS

41. Videourodynamic Findings in Female Bladder Outlet Obstruction • Presence of spontaneous DI • High voiding pressure and low flow rate • Moderate to large residual urine • Bladder neck narrowing or urethral narrowing (mid-urethra or distal urethra) • Coordinated EMG (stricture) or discoordinated EMG (dysfunctional voiding)

42. Dysfunctional voiding in a woman

43. Obstructive Uropathy due to Chronic Bladder Distension

44. Cystoscopic Findings in Bladder neck dysfunction

45. Appearance of Bladder neck after TUI-Bladder neck

46. Video Urodynamic results before and after TUI-Bladder neck

47. Resolution of hydronephrosis

48. Postoperative uroflowmetry and renalsonography

49. Diagnosis of BOO in Women • Alert in evaluation of LUTS in women • Do uroflowmetry and cystoscopy in women refractory to medication • Pressure flow study in women with trabeculated bladder and large residual urine • When bilateral hydronephrosis is found, always consider bladder outlet origin