Bladder outlet obstruction(BOO)

in women

Ingrid Nygaard, MD, MSProfessor

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 29%– Urgency 29%– Difficulty emptying 13%– Incomplete emptying 21%– Weak stream 19%– Intermittent stream 26%– Postvoid dribble 7%(Reported that symptom occurred ‘usually’ during past 3 months.)

Bradley, Kennedy, Nygaard 2005

Symptoms of BOO are commonWeekly Daily

Hesitancy 28% 16%

Straining 15% 8%

Incomplete emptying 16% 7%

Post void dribble 14% 4%

4,000 Danish women3/4 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 feeling of incomplete bladder emptying?”

47% 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• Difficulty emptying reported

by– 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

Others• BMI

– 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

symptomsBradley, 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 >6 weeks (catheter or revision)

BOO requiring surgery

Burch (n=329) 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%

Albo, Richter et al. NEJM 2007; Richter, Albo et al. NEJM 2010

Treatment of BOO following mid-urethral 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: TVT50 (0.6%): TVT release (mean 197 days after)

91% midline transection49%: retention cured and no new SUI88%: 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 obstructionPelvic 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 symptomsStress Continent Stress

IncontinentOR (95% CI)

No. women 296 82

% with bothersome symptoms

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

Irritative and obstructive symptoms, and bother

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 AnatomicUrethral 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 (akaPelvic 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 disorderMay respond to graduated exposure therapyShy 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 toiletHover (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 postureOnly 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 SlingSISTER trial

Baseline DO on UDS resolved in19/27 Burch (70%)10/18 Sling (56%)

New onset DO on UDSBurch 10/215 (5%)Sling 18/239 (8%)

New onset urge incontinence Burch 3%Sling 3%

Kraus, Lemack et al. Urology 2011Albo, Richter et al. NEJM 2007

TOMUSRetropubic 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 antimuscarinicsStarkman…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