Anatomic Bladder Outlet Obstruction Research Articles

Outcomes of women diagnosed with primary bladder neck obstruction based on video urodynamic criteria

AbstractObjectiveFunctional and anatomic bladder outlet obstruction (BOO) in women are more prevalent than previously suspected and remain a diagnostic challenge. Several urodynamic diagnostic criteria for female BOO have been proposed, but studies validating the criteria by assessing treatment outcomes are lacking. We sought to correlate video urodynamic (VUD) diagnostic criteria with symptom improvement in women with functional bladder outlet obstruction.MethodsA retrospective cohort study of women diagnosed with primary bladder neck obstruction (PBNO) by VUD criteria who underwent bladder neck incision (BNI) between 2010 and 2022 was performed. Patient demographic, clinical, and urodynamic characteristics were collected before and after treatment and analyzed.ResultsTwenty‐six women with mean age 64.7 years underwent BNI. Nineteen patients (73.1%) were cured, four (15.4%) improved, and three (11.5%) failed. After BNI the mean postoperative Qmax was significantly higher (9.4 vs. 3 mL/s, p = 0.006) and mean postvoid residual (PVR) was significantly lower (102 vs. 514 mL, p ≤ 0.001). Patients who did not require a catheter preoperatively were more likely to be cured than those who did (90% vs. 62.5%, p = 0.03). The PdetQmax of patients that were cured or improved did not differ significantly from those who were not (50.7 cm H2O vs. 32 cm H2O, p = 0.21).ConclusionsThe diagnosis of PBNO by VUD criteria for obstruction correlated with treatment outcomes with success in 88.5% and 56% becoming catheter independent. Successful treatment was independent of preoperative PdetQmax.

The effect of pelvic floor muscle training in women with functional bladder outlet obstruction.

Female voiding dysfunction is often due to bladder outlet obstruction (BOO). We investigated pelvic floor muscle training (PFMT) effectiveness in women with functional BOO. This is a prospective study recruiting 63 women functionally obstructed, over 18yo, maximum flow rate (Qmax) less than 12ml/sec, naïve of voiding treatment. Exclusion criteria were anatomical BOO, neurological condition, pelvic intervention, psychiatric or anticholinergic medication, diabetes mellitus and affected upper urinary tract. At baseline, women underwent uroflow, post void residual (PVR) measurement, cystoscopy, cystogram and urodynamic study (UDS) with pelvic electromyography (EMG). Blaivas-Groutz nomogram has been used to define obstruction. After diagnosis, patients underwent six-month PFMT. Re-evaluation was offered four weeks after end of treatment. Data were analyzed with SPSSv22.0. 63 women were recruited and 48 finally included. At baseline, 20 reported 3 urinary tract infections (UTIs) during last year, and 12 had one episode of urine retention. Median Qmax was 7.5ml/sec and median PVR 110ml. 40 women were obstructed. 16 (40%) had mild, 16 (40%) moderate and 8 (20%) severe obstruction. All subjects had an overactive pelvic floor on EMG. Obstructed women were re-evaluated. Median Qmax was 8.5ml/sec, close to baseline (p = 0.16). Median PVR was 65ml, reduced to baseline (p = 0.02). 33 (82.5%) remained obstructed, 22 (66.67%) with mild, 8 (24.24%) moderate and 3 (9.09%) severe obstruction. 7 (17.5%) were non-obstructed. 4 patients reported one UTI episode with no cases of retention. A 6month PFMT reduced UTIs and PVR in women with functional BOO. Additionally, most patients had a de-escalation to milder obstruction.

The Evidence For and Against Prostate-Reducing Procedures for Men with Neurogenic Bladder

The evaluation of anatomic bladder outlet obstruction due to benign prostatic hyperplasia in patients with neurogenic bladder dysfunction can be a challenging and complex process for urologists. Lower urinary tract symptoms are non-specific, and the attribution of symptoms to underlying neurologic disease may result in withholding potentially beneficial therapies and procedures from patients with benign prostatic hyperplasia. Conversely, the underlying neurologic disorder may have profound effects on lower urinary tract symptoms and quality of life and must be considered in patient management decisions. Thorough evaluation is necessary to evaluate male patients with concomitant benign prostatic hyperplasia and neurogenic bladder with careful attention to the underlying neurologic disease. While surgical management of anatomic bladder outlet obstruction has a clear role in carefully selected and thoroughly evaluated patients with neurogenic bladder, treatment strategies must be individualized for each patient. This review seeks to explore the role of prostate-reducing surgeries in management of patients with neurogenic bladder and to compile evidence for and against these procedures in this population. Only a few studies have been published exploring prostate-reducing surgery in the management of patients with neurogenic bladder, with no recent trials. These existing studies are poorly controlled and are characterized by small, heterogeneous study populations, retrospective design, and high risk of bias. While some studies suggest positive outcomes from prostate-reducing surgery for management of patients with neurogenic bladder, more high-quality trials are needed.

Internal Urethrotomy in Treatment of Female with Anatomical Bladder Outlet Obstruction.

Background:Bladder outlet obstruction (BOO) is a relatively infrequent urologic condition in women, but can cause bothersome symptoms. In this article, transurethral incisions of the bladder neck (TUIBN) and urethra in the treatment of anatomical BOO were assessed.Materials and Methods:A total of 23 women who referred with chronic lower urinary tract symptoms, urinary retention, and difficulty in micturition were assessed. Diagnose was made on the basis of urethrocystoscopy, voiding cystourethrography, and urodynamic studies. All patients underwent transurethral incisions of bladder neck contracture or site of observed urethral stenosis at 3- and 9-o'clock positions. Clinical improvements and complications were assessed by follow-up examination and International Prostate Symptom Score (IPSS) and quality of life (QOL) scoring before and after intervention.Results:All patients were followed for at least 6 months after intervention. Follow-up data were available for 19 (90.5%), 13 (61.9%), and 7 (33.3%) of patients at 12, 24, and 48 months' follow-up, respectively. During the follow-up period, the mean IPSS and QOL significantly changed from 26.84 to 10.74 and 4.76 to 2.32, respectively (P < 0.001). Approximately 66.7% had satisfactory outcomes, 47.7% patients after first, and 19.1% after second TUI. About9.5% patients developed new onset of stress urinary incontinence, one of them had indications of surgical intervention, and thus, symptoms were relieved by mid-urethral sling.Conclusion:Transurethral incision of bladder neck and urethra seems to be effective in relieving urinary symptoms of anatomical BOO in women. Complications may rarely occur and can be fully managed.

The Association of Urinary Nerve Growth Factor Levels With Bladder Outlet Obstruction in Women

Nerve growth factor (NGF) has been proposed as a urinary biomarker and previously shown to be elevated in male patients with bladder outlet obstruction (BOO) and other lower urinary tract symptoms. No published studies have examined NGF as a potential urinary biomarker in women with BOO. The aims of this prospective study were to evaluate NGF levels in urine from women with anatomic BOO resulting from pelvic organ prolapse (POP) and/or previous incontinence surgery and to measure the effect associated with surgical or conservative management. From January to September 2012, all female patients referred for evaluation and management of BOO from POP or previous incontinence surgery were screened for enrollment. Inclusion criteria included elevated postvoid residual, valsalva voiding on urodynamics, or urinary peak flow (Qmax) of 12 mL/s or less. A control group of 10 asymptomatic age-matched female volunteers was also recruited. In all subjects, urinary NGF and creatinine (Cr) levels were measured and normalized to the urinary Cr concentrations (NGF/Cr). Urinary NGF levels were measured at 1 month and 3 months after either surgical correction or initiation of clean intermittent catheterization. A total of 10 female patients with anatomic BOO (mean [SD] age of 66.2 [3.88] years) and 10 female control subjects (mean [SD] age of 62 [7] years) were recruited. Nine patients had POP. Six patients had undergone a previous anti-incontinence procedure. Five patients had both POP and undergone a previous anti-incontinence procedure. The urinary NGF/Cr levels in the study patients with BOO (mean [SE] 20.8 [4.31] pg/mg) were significantly higher (P = 0.0001) than the levels in the age-matched control group (5.6 [0.65] pg/mg). After treatment, the urinary NGF/Cr level significantly decreased to 6.50 (0.57) pg/mg (P = 0.01) CONCLUSIONS: In this study, female patients with anatomic BOO resulting from POP and/or previous incontinence surgery had significantly higher urinary NGF/Cr levels when compared with age-matched controls. After treatment, the urinary NGF/Cr levels significantly decreased.

Urodynamic diagnosis of female bladder outlet obstruction

Female bladder outlet obstruction (BOO) remains a controversial topic in terms of definition and diagnosis. It is a condition that is far less common in women than in men and has an estimated incidence of 2.7e8%.1,2 The etiology for organic BOO or anatomic BOO (but not including functional BOO) is more diverse in women because of various anatomical or iatrogenic changes affecting vaginal support, the urethra, and/or the bladder. Some changes such as prolapse are related to aging, whereas other changes are related to urethral pathology or previous surgeries (e.g., sling procedure, urethropexy). Furthermore, the urethral anatomical sites for BOO can be further subcategorized by extrinsic compression, urethral wall conditions (e.g., fibrosis, urethral diverticulum), or luminal factors (e.g., stricture disease).3 Owing to the complexity of etiology and nonspecific voiding symptoms, the diagnosis of female BOO requires a high index of suspicion and recourse to a variety of modalities, and includes a thorough history, questionnaires, noninvasive flow and residual assessment, physical examination, cystoscopy, imaging, and urodynamic or videourodynamic studies.

MP75-18 REEVALUATION OF CUT-OFF VALUES FOR BLADDER OUTLET OBSTRUCTION BASED ON PRESSURE-FLOW STUDIES FROM ANATOMICALLY OBSTRUCTED WOMEN

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Urology II1 Apr 2014MP75-18 REEVALUATION OF CUT-OFF VALUES FOR BLADDER OUTLET OBSTRUCTION BASED ON PRESSURE-FLOW STUDIES FROM ANATOMICALLY OBSTRUCTED WOMEN Philippe E. Zimmern, Omer Gulpinar, Alana Christie, Jack Hou, Feras Alhalabi, and Gary E. Lemack Philippe E. ZimmernPhilippe E. Zimmern More articles by this author , Omer GulpinarOmer Gulpinar More articles by this author , Alana ChristieAlana Christie More articles by this author , Jack HouJack Hou More articles by this author , Feras AlhalabiFeras Alhalabi More articles by this author , and Gary E. LemackGary E. Lemack More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2391AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To refine the definition of pressure-flow study cut-off values for anatomic female bladder outlet obstruction (BOO) by comparing these urodynamic parameters in women with clinical obstruction due to 3 different obstructive mechanisms. METHODS Following IRB approval, urodynamic data from 3 groups of women with BOO were reviewed, including Group 1: obstruction after sling placement, Group 2: symptomatic Stage 3-4 anterior vaginal prolapse, Group 3: meatal stricture or distal urethral fibrosis. BOO diagnosis was based on history, presenting symptoms, exam findings, and site of obstruction confirmed on lateral voiding cystogram. Urodynamic testing was done according to prior reported protocol (ref 1), with tracings excluded for abdominal straining (Pabd > 10 cm H2O). The optimal combination of maximal flow rate (Qmax) and detrusor pressure at maximal flow rate (PdetQmax) for determining BOO was calculated using nonparametric receiver operating characteristic (ROC) curves. Box and whisker plots were used for group comparison. RESULTS In the past 9 years, 146 non-neurogenic women with clinically-confirmed anatomic BOO (age 61 [41-87]) were studied in comparison to 42 age-comparable controls (age 63 [42-85]). The area under the curve for the ROC was 0.886 for Qmax and 0.778 for PdetQmax. For the Qmax cut-off of 15, the sensitivity and specificity were 0.78 and 0.82 respectively, while for Pdet Qmax cut-off of 25, they were 0.76 and 0.72 respectively (Fig .1). Age, Qmax, and PdetQmax were similar among the three BOO groups, except for lower Qmax in Group 3 versus Group 1 (Fig. 2) CONCLUSIONS This data confirms and reinforces prior data (1) on cut-off values for BOO in women. Reference: 1. Defreitas et al. Urology 64:675-681, 2004. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e880-e881 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Philippe E. Zimmern More articles by this author Omer Gulpinar More articles by this author Alana Christie More articles by this author Jack Hou More articles by this author Feras Alhalabi More articles by this author Gary E. Lemack More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Epidemiology and etiology of benign prostatic hyperplasia and bladder outlet obstruction

Benign prostatic hyperplasia (BPH) is a histological diagnosis associated with unregulated proliferation of connective tissue, smooth muscle and glandular epithelium. BPH may compress the urethra and result in anatomic bladder outlet obstruction (BOO); BOO may present as lower urinary tract symptoms (LUTS), infections, retention and other adverse events. BPH and BOO have a significant impact on the health of older men and health-care costs. As the world population ages, the incidence and prevalence of BPH and LUTS have increased rapidly. Although non-modifiable risk factors – including age, genetics and geography – play significant roles in the etiology of BPH and BOO, recent data have revealed modifiable risk factors that present new opportunities for treatment and prevention, including sex steroid hormones, the metabolic syndrome and cardiovascular disease, obesity, diabetes, diet, physical activity and inflammation. We review the natural history, definitions and key risk factors of BPH and BOO in epidemiological studies.

The Therapeutic Effects of Repeated Detrusor Injections Between 200 or 300 Units of OnabotulinumtoxinA in Chronic Spinal Cord Injured Patients

To investigate the therapeutic effects of repeated detrusor onabotulinumtoxinA injections on treatment outcomes, quality of life (QoL), and glomerular filtration rate (GFR) in chronic spinal cord injured (SCI) patients with neurogenic lower urinary tract dysfunction and urinary incontinence. Patients with SCI who failed antimuscarinic treatment were enrolled. All patients had urodynamic detrusor overactivity (DO) or increased detrusor tonicity without anatomical bladder outlet obstruction or intrinsic sphincter deficiency. They were randomly assigned to receive 200-U or 300-U onabotulinumtoxinA detrusor injections every 6 months. The primary endpoint was 6 months after the second injection. The urodynamic parameters, QoL measures, and 99mTc renal scans were evaluated at baseline and every 3 months and compared between dosages. A total of 72 patients were enrolled, including 43 men and 29 women and mean injury duration of 8.7 years. Among them, 38 patients received 200-U and 34 received 300-U onabotulinumtoxinA injections. At the end-point, the urodynamic parameters and incontinence severity improved significantly, without a significant difference between the two groups. QoL also improved in both groups, without differences between groups. Uninhibited DO improved more in 300-U group compared to 200-U group at end-point (P = 0.01). The GFR did not change significantly in either group. The most common complication was urinary tract infection, which occurred in one third of patients. Either 200-U or 300-U repeated detrusor onabotulinumtoxinA injections improved incontinence, urodynamic parameters, and QoL in SCI patients with neurogenic DO. Renal function was maintained in patients receiving both dosage of repeated injections.

Comparison of Urodynamic Findings in Women With Anatomical Versus Functional Bladder Outlet Obstruction

To characterize the symptoms and urodynamic findings of anatomical bladder outlet obstruction (AO) and functional bladder outlet obstruction (FO) in women and to determine if future endeavors at defining bladder outlet obstruction in women can group these entities together. Retrospective review of all videourodynamic studies was performed on women from March 2003 to July 2009. Women with diagnosis of obstruction were categorized based on the cause of obstruction into 2 groups: AO and FO. Demographic data, symptoms, and urodynamic findings were compared between the 2 groups. One hundred fifty-seven women were identified of which 86 (54.8%) were classified as having AO and 71 (45.2%) were classified as having FO. There were no differences in symptoms between the 2 groups. There was no difference (P=0.5789) in the mean detrusor pressure at maximum flow rate Qmax between AO (38.9 cm H20) and FO (41.0 cm H20). There was a difference in the Qmax between AO and FO (10.6 [0-41.7] and 7.4 [0-35.7] mL/s, respectively; P=0.0044), but there was considerable overlap between the values in these 2 groups. Anatomical bladder outlet obstruction and FO have similar urodynamic voiding pressure findings, but Qmax was statistically significantly lower in AO. However, there is a large overlap in the Qmax values between the 2 groups. Therefore, future studies that attempt to characterize bladder outlet obstruction in women need not exclude either group.

Efficacy and Safety of Tamsulosin for the Treatment of Non-neurogenic Voiding Dysfunction in Females: A 8-Week Prospective Study

We evaluated the therapeutic effects of tamsulosin for women with non-neurogenic voiding dysfunction. Women who had voiding dysfunctions for at least 3 months were included. Inclusion criteria were age ≥18 yr, International Prostate Symptom Score (IPSS) of ≥15, and maximum flow rate (Qmax) of ≥12 mL/sec and/or postvoid residuals (PVR) of ≥150 mL. Patients with neurogenic voiding dysfunction or anatomical bladder outlet obstruction were excluded. All patients were classified according to the Blaivas-Groutz nomogram as having no or mild obstruction (group A) or moderate or severe obstruction (group B). After 8 weeks of treatment, treatment outcomes and adverse effects were evaluated. One hundred and six patients were evaluable (70 in group A, 36 in group B). After treatments, mean IPSS, bother scores, Qmax, PVR, diurnal and nocturnal micturition frequencies and scored form of the Bristol Female Lower Urinary Tract Symptoms questionnaire (BFLUTS-SF) were changed significantly. Eighty-nine patients (84%) reported that the treatment was beneficial. The proportion of patients reported that their bladder symptoms caused "moderate to many severe problems" were significantly decreased. No significant difference were observed between the groups in terms of IPSS, bother score, Qmax, PVR, micturition frequency, and BFLUTS-SF changes. Adverse effects related to medication were dizziness (n=3), de novo stress urinary incontinence (SUI) (n=3), aggravation of underlying SUI (n=1), fatigue (n=1). Tamsulosin was found to be effective in female patients with voiding dysfunction regardless of obstruction grade.

Predictive Factors for Female Bladder Outlet Obstruction Defined by Pressure-Flow Study

Purpose: We investigated pre-urodynamic study parameters of bladder outlet obstruction (BOO) defined by pressure-flow study (PFS) in female patients without anatomical obstruction. Materials and Methods: The cohort of this study consisted of 320 women who did not have anatomical BOO in whom urodynamic study was conducted for lower urinary tract symptoms (LUTS). BOO was defined when the PFS maximal flow rate (Qmax) was ≤12 ml/sec and Pdet Qmax was ≥25 cmH2O. The main outcomes were the incidence of BOO and its predictive factors in our cohort. Results: Of the total patients, 39 (12.2%) were diagnosed with BOO in the PFS. Free Qmax and maximal voided volume (MVV) were significant predictors of BOO (p 15 ml/sec or MVV is >350 ml, PFS may be not essential. On the contrary, if free Qmax and MVV are below these levels, PFS may be indicated to evaluate the presence of BOO. (Korean J Urol 2009;50: 848-853) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Refining diagnosis of anatomic female bladder outlet obstruction: comparison of pressure-flow study parameters in clinically obstructed women with those of normal controls

Objectives To improve the definition of pressure-flow study cutoff values for anatomic female bladder outlet obstruction (BOO) by comparing these parameters in women with clinical obstruction with those of normalcontrols. Methods Inthe past 3 years, 82 consecutive women with clinical anatomic BOO were investigated according to an institutional review board-approved protocol that included imaging and urodynamic studies. The data fromthese women were then added to those of our previously published cohort of 87 patients. The controls were 20 female volunteers without any urologic complaints and without a history of bladder or urethralsurgery who had undergone a urodynamic study. Three groups of women with BOO were identified in the most recent cohort: 20 with StageIII-IV cystocele, 23 who had undergone previous anti-incontinence surgery, and 39 with distal periurethral fibrosis or stricture. Theoptimal combination of the maximal flow rate (Qmax) and detrusor pressure at maximal flow rate (PdetQmax) for determining BOO wascalculated using nonparametric receiver operating characteristic curves for the entire cohort of 169 women withobstruction. Results Age,Qmax, and PdetQmax were similar among the three BOO groups. The area under the receiver operating characteristic curve for BOO was 0.762 for Qmax (95% confidence interval 0.661 to 0.864, P <0.001) and 0.721 for PdetQmax (95%confidence interval 0.617 to 0.824, P <0.001). After adjusting for the effect of age, PdetQmax( P <0.001) and Qmax ( P<0.011) were independently associated with BOO. Conclusions After adjusting for age and using normal controls rather than an incontinentcontrol population, we present pressure-flow study cutoff values to aid in the urodynamic study diagnosis of women with anatomicBOO.

Acquired Structural Genitourinary Abnormalities Contributing to Deterioration of Renal Function in Older Patients with Nephropathic Cystinosis

The natural progression of nephropathic cystinosis to end stage renal disease can be delayed, sometimes by many years, by the reducing agent, cysteamine, which lowers intracellular cystine content to near normal. We report on two patients with nephropathic cystinosis who were treated with cysteamine and developed structural genitourinary abnormalities which may have contributed to an increase in the rate of decline of renal function. One patient, aged 11 years, was found to have massive megacystis and hydroureteronephrosis but no anatomic bladder outlet obstruction. His abnormality was presumed to be related to chronic high urine volumes leading to megacystis and physiologic ureteral obstruction. Vesicostomy stabilized renal function. The second patient, aged 11 1/2 years, was found to have bilateral renal cystic disease which presumably was acquired and may have been related to long-standing hypokalemia. Minor renal abnormalities were found by ultrasound in five additional cystinotic children. We concluded that older children with nephropathic cystinosis may be prone to acquire structural abnormalities of their kidneys or urinary tract.

Medical outcomes research and benign prostatic hyperplasia

Increasing health care costs and growing interest in quality care have focused attention on medical outcomes research. With regard to symptomatic BPH, patients deciding between different treatment choices need to know the likely outcomes of these alternatives, including chances for symptom responses and improved functional health and well-being. There is a paucity of high-quality outcomes research in medicine, including research that would clarify treatment outcomes for BPH. The relationship between physiologic and anatomic bladder outlet obstruction due to BPH and its symptoms, as well as quality of life, needs further study to elucidate how BPH affects health. A number of ongoing studies should provide information on the outcomes of alternative treatment strategies for BPH, the relationship between anatomic and physiologic BPH, and higher-level outcomes, such as symptom levels and quality of life.

Uroflowmetry in neurologically normal children with voiding disorders.

A prospective study was undertaken to delineate the role of spontaneous uroflowmetry as screening procedure for functional infravesical obstruction (detrusor/sphincter dyssynergia). More than 70% of thirty-nine children referred for urinary tract infections and/or enuresis in the absence of neurological deficits underwent a complete diagnostic program including intravenous urography, voiding cystography and cystoscopy as well as spontaneous uroflowmetry, cystometry-emg and pressure-flow-emg study. The incidence of dyssynergia was 22%. However, neither the flow curve pattern nor single flow variables were able to identify children with dyssynergia. Consequently uroflowmetry seems inefficient in the screening for dyssynergia in neurological normal children with voiding disorders in the absence of anatomical bladder outlet obstruction.