Bladder Outlet Obstruction in Women - University of Utah

Report
Bladder outlet obstruction
(BOO)
in women
Ingrid Nygaard, MD, MS
Professor
University of Utah
Objectives
• Describe both voiding and storage symptoms
of BOO in women.
• Understand the association between voiding
symptoms of BOO and objective findings of
BOO.
• State the role of urethral dilation in treating
BOO in women.
• Describe the most optimal time period to
intervene in BOO following mid-urethral sling.
Symptoms of BOO
• Voiding symptoms
–
–
–
–
–
–
–
Hesitancy
Straining
Incomplete emptying
Post void dribbling
Slow stream
Splayed stream
Urethral pain
• Storage symptoms
– Urgency, frequency, OAB
– Urgency incontinence
Symptoms of BOO are common in
women
• Amongst 297 women, mean age 68, not seeking
care:
–
–
–
–
–
–
–
Frequency
Urgency
Difficulty emptying
Incomplete emptying
Weak stream
Intermittent stream
Postvoid dribble
29%
29%
13%
21%
19%
26%
7%
(Reported that symptom occurred ‘usually’ during past 3 months.)
Bradley, Kennedy, Nygaard 2005
Symptoms of BOO are common
Weekly
Daily
Hesitancy
28%
16%
Straining
15%
8%
Incomplete emptying
16%
7%
Post void dribble
14%
4%
4,000 Danish women
3/4 had symptom “sometimes”
MØLLER, LOSE, JØRGENSEN. Acta Obstet Gynecol Scand 2000
Given that symptoms are common, how well do
they correlate with ‘objective’ evidence of
obstruction?
Predictive value of obstructive voiding
symptoms and tests
In 95 women visiting urogyn clinic for LUTS:
Positive response
Positive Predictive Value
(compared to PVR > 50 ml)
“Do you usually experience 47%
feeling of incomplete
bladder emptying?”
0.16
Max flow < 10th%
34%
0.29
Low flow and high
pressure during voiding
20%
0.28
[Jeon and Yoo, 2012]
Obstructive symptoms and PVR
• 636 women presenting to urogyn clinic
• Stage I-II: PVR 41 (SD 51); 3% had PVR > 150 ml
• Stage III-IV: PVR 67 (SD 92); 10% had PVR > 150
ml
• Moderate/great bother by
– feeling incomplete emptying:
• Yes: PVR 56 (SD 78)
• No: PVR 40 (SD 56)
– Difficulty emptying bladder
• Yes: PVR 48 (SD 45)
• No: PVR 44 (SD 48)
[Lowenstein….Brubaker, Int Urogyn J
2008]
If symptoms aren’t discriminatory
• Should we:
– Investigate all women with BOO symptoms?
– Or investigate no women with BOO symptoms and
consider these ‘normal findings’?
• My preference: Check PVR and proceed from
there.
Etiology of BOO in women
• Lifestyle factors
• Overactive outlet
• Anatomic obstruction
– Iatrogenic (SUI surgery)
– Pelvic organ prolapse (POP), tumor
– Urethral (traumatic, stenosis, stricture)
– Congenital/neoplasm/DSD/inflammatory
• Behavioral (“Pseudodyssynergia”, “Shy
bladder”)
Obstructive symptoms and lifestyle factors
Coffee
Others
• Difficulty emptying
reported by
• BMI
– 15% of coffee drinkers
– 3% non-coffee drinkers
• P=0.01
• Weak stream reported by
– 23% of coffee drinkers
– 5% non-coffee drinkers
• P<0.01
• ORs 5-8 adjusted for age,
BMI, smoking, exercise
– Urgency OR 1.8 (0.8, 4.0)
– UUI OR 2.2 (1.0, 4.8)
• Exercise > weekly
– Urgency OR 0.6 (0.4, 1.0)
• Smoking
– No effect on any BOO
symptoms
• Age
– Increased odds of most
BOO symptoms
Bradley, Kennedy, Nygaard 2005
Overactive outlet
• Medications that increase resistance
– Alpha adrenergic agonists (phenylpropanolamine)
– SSRI (duloxetine)
– Beta adrenergic
antagonists (propranol)
SUI surgery and subsequent BOO
(UITN studies)
New UUI
Voiding dysfunction BOO requiring
>6 weeks (catheter surgery
or revision)
3%
2%
0%
Fascial sling (n=326) 3%
14%
6%
Retropubic MUS
(n=298)
0%
3.4%
2.7%
Transobturator
MUS (n=299)
0.3%
1.3%
0%
Burch (n=329)
Albo, Richter et al. NEJM 2007; Richter, Albo et al. NEJM 2010
Treatment of BOO following midurethral sling
• When?
• Where?
• How?
• NB: STEP 1: Ensure patient is not straining to
void!
When to intervene?
• 2002: Experience of 4 US centers during early years of TVT
• N=23: Some improvement in 3 of 11 that tried meds and in
1 of 7 that tried dilation
• median interval between TVT and release 8.6 weeks
– 10: general anesthesia
– 13: local and IV sedation
– 1: office with local
• 17 midline lysis only
• 100% relief of impaired emptying by 2 weeks
• Continence status: cure: 61%, improved 30%
Rardin, Rosenblatt, Kohli et al. Obstet Gynecol
2002
Success of sling release
Finnish registry by end 2002 (early days of TVT)
9040: TVT
50 (0.6%): TVT release (mean 197 days after)
91% midline transection
49%: retention cured and no new SUI
88%: retention cured
Laurikainen, Kiilholma Int Urogyn J 2006
Timing of sling intervention
• Delayed intervention: good success at
restoring voiding but lower cure rate
• Early intervention: better success at restoring
voiding and better cure rate
– And, early timing allows attempts to mobilize sling
Early mobilization
• 10 women unable to void after TVT
• Mobilization in OR POD 3-10. All voided and
catheter out by 48 hours.
• No difference in continence.
• Bottom line: Mobilize if no void by POD 3.
Nguyen J. Urology 2005
Early mobilization
• Mobilization in OR under general anesthesia
– N=33:TVT mobilized and loosened within 2 weeks
– Voiding function normal in 29; 4 underwent later
release
• Price…Jackson. International Urogynecology 2009
• Mobilization on floor under local
– 3-0 vicryl loop placed at midpoint of tape and pulled
– 5/80 received mobilization on POD 1-3. Immediately
successful in 4, 1 needed 3 adjustments. None had
recurrent SUI.
• Chang, Sheu, et al: International Urogynecology 2010
Voiding dysfunction after mid-urethral
sling: Bottom line
• Uncommon
• More with retropubic than transobturator
approach
• Generally, no pre-op testing, other than PVR,
required
• Intervene early
• Try mobilization first
• Early surgical treatment resolves retention about
90% of time; low risk of new SUI
BOO due to anatomic obstruction
Pelvic Organ Prolapse (POP)
POP-Q stage
PVR*
0
25 (0-270) [median, range]
1
30 (0-250)
2
45 (0-700)
3,4
50 (0-350)
*cath, 5 min post void
Cetinkaya et al, 2013
Women with POP and SUI have more bladder symptoms
Stress Continent Stress
Incontinent
No. women
OR (95% CI)
296
82
Irritative
47%
80%
0.22 (0.11–0.42)
Nocturia
31%
55%
0.35 (0.20–0.62)
Enuresis
0.3%
8%
0.05 (0.00–0.55)
Dysuria
12%
20%
0.67 (0.32–1.40)
Voiding
49%
72%
0.36 (0.20–0.66)
PVR
87 ml
66 ml
% with bothersome
symptoms
Richter, Nygaard et al. J Urol 2007
↑PVR resolves after POP surgery
• 35 women undergoing POP op with PVR >100
(mean 226 ml)
• Post op, PVR normal in 89%
• [Fitzgerald, Fenner 2000]
• 57 women undergoing POP op with PVR>100
• Post op, PVR <100 in 84%
• [Liang et al 2008]
Urethral dilation
• UK survey 2006 of urologists
• Indication
– Urethral stenosis 97%
– LUTS with inadequate bladder
emptying 72%
– Idiopathic acute retention: 49%
– Chronic retention: 35%
• How often used in past year?
–
–
–
–
–
1-3: 18%
4-6: 21%
7-15: 26%
16-30: 20%
>30: 15%
• In what % of women do you
find urethral stenosis?
–
–
–
–
<25%: 69%
25-50%: 17%
50-75%: 9%
>75%: 4%
• In what % do you see
significant improvement?
–
–
–
–
<25%: 17%
25-50%: 38%
50-75%: 36%
>75%: 9%
Masarani and Willis, 2006
Is urethral stricture treated by urethral dilation?
Or
Does urethral dilation cause urethral stricture?
BOO Anatomic
Urethral stricture
• Accounts for 4-18% of women with BOO
• Much less prevalent in women
• Etiologies:
– Iatrogenic: Diverticulectomy, fistula repair, SUI surgery, tumor resection,
repetitive dilation
– Traumatic: prolonged cath, pelvic fracture
– Infectious: gonorrhea, tuberculosis
– Radiation therapy
• Diagnosis: cystoscopy, urethral calibration
– “In our experience, a urethra too narrow to admit a 17Fr flexible cystoscope
that has the feel of scar tissue by haptic feedback is diagnostic.”
– Visual circumferential narrowing
• N=17 in 12 years
• 1 of 17 had sustained response to dilation alone
Blaivas et al. J Urol 2012
Conclusion of large review
• “There is no evidence supporting an appropriate
role for urethral dilation (UD) in girls and women
with dysfunctional voiding.” “There seems to be
no role for UD in pure functional BOO.”
• “The value of UD in treating female urethral
stricture disease, a rather rare entity, has not
been consistent between studies”
• “UD is a well recognized risk factor for stricture
development.”
• Bazi, Abou-Ghannam, Khauli, Int Urogynecol J, 2013
Overactive pelvic floor (aka
Pelvic floor hypertonic disorder) and
BOO
• Primary symptoms: pain, defecation disorder
• Botox studied for pain, vestibulodynia, pelvic
floor myalgia, pelvic floor spasm
Shy Bladder (AKA Paruresis)
?Subtype of social anxiety disorder
?Physiologic disorder
May respond to graduated exposure therapy
Shy Bladder Scale recently developed
Only with education and research, in addition to clarification and
agreement of the terminology for this phenomenon, can
progress be made in understanding and effectively treating
paruresis. Soifer…Chancellor. Urol Nurs 2009
Posture on public toilet
Hover (crouch)
• 40% Australian volunteers (Rane, 2007)
• 85% British GYN patients (Moore, 1991)
• 149% increase in PVR in crouch position
• 89% Chinese university students (Yang, 2010)
– 18% bell-shaped flow curve compared to 51%
sitting
Posture on toilet
Lean forward position: higher Qmax and Qavg
than sit back posture or knee raising posture
Only 46% of Australian volunteers could squat,
so couldn’t test whether this position better
Rane, Ajay (2011) Does posture affect micturition?
PhD thesis, James Cook University.
BOO and storage symptoms (“OAB”)
Pubmed search: “bladder outlet obstruction”
and “overactive bladder”
1/50 studies are not about men or rats.
Outlet obstruction
Altered receptor function, myogenic
denervation, imbalance of neurotransmitters
Detrusor Overactivity
2 years after Burch or Sling
SISTER trial
Baseline DO on UDS resolved in
19/27 Burch (70%)
10/18 Sling (56%)
New onset DO on UDS
Burch 10/215 (5%)
Sling 18/239 (8%)
New onset urge incontinence
Burch 3%
Sling 3%
Kraus, Lemack et al. Urology 2011
Albo, Richter et al. NEJM 2007
TOMUS
Retropubic
Transobturator
Change UDI irritative
-31
-33
Change UDI obstructive
-15
-15
New urge incontinence by
6 weeks
0/298
1/299
Persistent urge
incontinence at 6 weeks
12%
10%
Persistent urgency
14%
13%
Richter, Albo et al. NEJM 2010
Sling take-down improves obstruction
better than OAB
• 40 women underwent urethrolysis
• 28/34 with obstructive symptoms resolved
• 12/36 with OAB symptoms resolved
– 56% were on antimuscarinics
Starkman…Dmochowski. J Urol 2008
Objectives
• Describe both voiding and storage symptoms of BOO in
women.
– Most bladder symptoms except SUI
• Understand the association between voiding symptoms
of BOO and objective findings of BOO.
– Not much
• State the role of urethral dilation in treating BOO in
women.
– Don’t do it
• Describe the most optimal time period to intervene in
BOO following mid-urethral sling.
– Early

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