排尿障礙治療中心版權所有 Bladder Outlet Obstruction in Women Hann-Chorng Kuo Department...

排尿障礙治療中心版權所有

Bladder Outlet Obstructionin Women

Hann-Chorng KuoDepartment of Urology

Buddhist Tzu Chi General Hospital


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


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 BO

O contributed equally• Detrusor instability coexists with BOO• Patients may present with storage LUT

S


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


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


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%


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


Bladder neck dysfunction in woman


Urethral stricture in woman• Definite urethral scarring can be found in cys

tourethroscopy or urethrogram• History of indwelling Foley catheter or trans

urethral surgery• Obstructive type low flow rate• Coordinated urethral sphincter EMG during v

oiding phase• Relief of obstructive symptom after urethral

dilatation• Medication are not always effective


Urethral Stricture


Dysfunctional voiding in woman

• Spastic urethral sphincter as etiology• Learned habit?• May present with frequency urgency d

ysuria and/or urge incontinence• Cystourethrography revealed spinnin

g top appearance• Patient may have bilateral VU reflux o

r recurrent UTI


Spastic urethral sphincter (Dysfunctional voiding)


External compression of urethra• Infrequent cause of bladder outlet obstructi

on in women• Prolapse of uterus or uterine tumor compre

ssion 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


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 ureth

rovesical angle


Iatrogenic urethral obstruction


Detrusor instability developed after Bladder neck suspension


Uterine prolapse and Cystocele• Gr 5 cystocele and uterine prolapse ca

use angulation of urethrovesical angle• Patient always uses manual reduction

of bladder to void• Large residual urine and low flow rate• May mask intrinsic sphincter deficienc

y during leak point pressure measurement


Cystocele and Uterine Prolapse


Uterine prolapse and BOO


Reduction of cystocele relieves BOO


Obstructive uropathy in prolapse


Urethral meatal stenosis


Comparison of Qmax in BOO and non-BOO women


Comparison of detrusor pressure in BOO and non-BOO women


Nomogram for Female BOO


Blaivas BOO nomogram


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


Surgical Treatment for Female BOO

• Transurethral incision of bladder neck• Urethral dilatation• Transurethral sphincterotomy• Meatotomy• Transvaginal urethrolysis


Isolated urethral sphincter obstruction in detrusor areflexia


Botulinum A toxin sphincter injection• Botulinum A toxin is an inhibitor of acetylch

oline 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


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 residu

al urine and MUCP (Schurch 1996)• Transperineal injection of BTX-A in 6 SCI improved voidi

ng function (Schurch et al 1997)• Improved bladder capacity and decreased maximal detr

usor 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)


Botulinum A toxin therapy• 100 units (1vial) is diluted to 2ml• 50 units will be used in the first trial, 4 equiv

alent 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)


Botulinum A toxin injection in women


Botulinum A toxin injection in Spinal cord injured woman with DESD


Reduction of MUCP after Botulinum A toxin injection


Urethral Injection of Botulinum A toxin for Female BOO


Transurethral incision of urethral sphincter• Total incontinence after sphincterotomy• Indicated in quadriplegia women with adeq

uate detrusor contractility and DESD, recurrent UTI or upper tract deterioration

• Crede maneuver may be indicated• Irreversible procedure, should be performe

d with adequate informed consent• Botulinum toxin injection maybe another al

ternative


Detrusor instability and Female BOO• In women with frequency urgency an

d 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


Dysfunctional voiding and bilateral VUR in a woman with incontinence


Screening of BOO in Women with LUTS• Patient with urge incontinence after an

ti-incontinence surgery• Urge incontinence associated with dysu

ria, refractory to medication• A low maximal flow rate with plateau fl

ow pattern,nor respond to medication• Elderly women with frequency & dysuri

a• Previous catherization and LUTS


Videourodynamic Findings in Female Bladder Outlet Obstruction• Presence of spontaneous DI• High voiding pressure and low flow rat

e• Moderate to large residual urine• Bladder neck narrowing or urethral nar

rowing (mid-urethra or distal urethra)• Coordinated EMG (stricture) or discoor

dinated EMG (dysfunctional voiding)


Dysfunctional voiding in a woman


Obstructive Uropathy due to Chronic Bladder Distension


Cystoscopic Findings in Bladder neck dysfunction


Appearance of Bladder neck after TUI-Bladder neck


Video Urodynamic results before and after TUI-Bladder neck


Resolution of hydronephrosis


Postoperative uroflowmetry and renalsonography


Diagnosis of BOO in Women

• Alert in evaluation of LUTS in women• Do uroflowmetry and cystoscopy in w

omen refractory to medication• Pressure flow study in women with tra

beculated bladder and large residual urine

• When bilateral hydronephrosis is found, always consider bladder outlet origin

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Transcript of 排尿障礙治療中心 版權所有 Bladder Outlet Obstruction in Women Hann-Chorng Kuo Department...

排尿障礙治療中心版權所有 Bladder Outlet Obstruction in Women Hann-Chorng Kuo Department...

Transcript of 排尿障礙治療中心版權所有 Bladder Outlet Obstruction in Women Hann-Chorng Kuo Department...