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 PdetQmaxgt50 cm water and Qmax
  lt12 ml/s
• Axelrod Blaivas sustained PdetQmax gt20 cm
  water and Qmax lt12 ml/s
• Chassagne et al PdetQmaxgt20 cm water and Qmax
  lt15 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 lt15ml/s and
  Pdet.Qmax gt20cmH2O
• Nitti(1999)76/331(23)with radiographic urethral
  narrowing and reduced flow
• Groutz(2000)38/587(6.5) with Qmax lt12ml/s and
  Pdet.Qmax gt20cmH2O

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