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Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

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Diagnosis Suspect in: –all women with low Q –with grade 3 & 4 POP –sx onset after incontinence/ prolapse surgery Urodynamics (synchronous pdet / Q) Cystoscopy

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Page 1: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Urethral Obstruction

Jerry G. Blaivas, MDClinical Professor of UrologyWeil Cornell Medical College

New York Presbyterian Medical Center

Adjunct Professor of UrologySUNY Downstate Medical Center

Page 2: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Urethral Obstruction

• Incidence: 2 - 29% of women with persistent LUTS

• Symptoms: nothing characteristic– storage 29%– voiding 8%– both 63%

B Blaivas & Groutz, , Neurourol & Urodynam 19:553, 2000; Nitti et al, J Urol, 1999

Page 3: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Diagnosis

• Suspect in:– all women with low Q– with grade 3 & 4 POP– sx onset after incontinence/ prolapse surgery

• Urodynamics (synchronous pdet / Q)

• Cystoscopy

Page 4: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Urethral obstruction

• High detrusor pressure(pdet > 20 cm H20)

• Low uroflow(Qmax < 12 ml/S)

Page 5: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

2

Strss

High pressure

Low flow

Page 6: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Impaired Detrusor Contractility

• Weak & or poorly sustained detrusorcontraction (pdet < 20 cm H20)

• Low flow (Qmax < 12 ml/S)

Page 7: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

JK

Low pressure

Low flow

Page 8: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Blaivas - Groutz Nomogram

0

20

40

60

80

100

120

140

160

0 10 20 30 40 50Free Qmax (ml/ sec)

pdet

.max

(cm

H2O)

Moderate obstruction (2)

Severe obstruction (3)

Mild obstruction (1)Unobstructed (0)

Blaivas & Groutz, Neurourol & Urodynam 19:553-564, 2000.

Page 9: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Diagnosis• ”…radiographic evidence of obstruction…

in the presence of a sustained detrusor contraction.”

• No specific UDS criteria

• Obstructed women had:– lower Qmax – higher Pdet@Qmax – higher PVR

• 23% of 331 women were obstructed

Nitti et al, J Urol, 1999

Page 10: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Caveats• A pressure flow diagnosis is usually

definitive, but

• An acontractile detrusor or impaired detrusor contractility does not rule out obstruction

• Persistent voiding dysfunction after incontinence surgery is usually due to obstruction

Page 11: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Etiology

Groutz et al, Neurourol Urodyn 19:213,2000; Nitti et al., 1999

Prior surgery 14 - 30%

Prolapse 29%

Stricture 15%1O bladder neck obstruction 10 - 16%

DESD 6%

Dysfunction voiding 6 - 33%

Urethral diverticulum 4%

Page 12: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Urethral Obstruction in women

• Anatomic

• Functional

Page 13: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic• Idiopathic

• Atrophy

Page 14: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Functional Urethral Obstruction

• Primary vesical neck

• Neurogenic

• Acquired behavior

Page 15: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Rx Anatomic Urethral Obstruction

• Intermittent catheterization

• Surgery - depends on the cause:– correct prolapse– sling incision / urethrolysis– urethral diverticulectomy– urethroplasty

Page 16: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Rx Functional Urethral Obstruction

• Primary vesical neck• TUI / TUR of vesical neck• ? Alpha adrenergic antagonists

• Neurogenic• Intermittent catheterization +/-

• anticholinergics• Botox• enterocystoplasty

• Dysfunctional voiding•Bmod / biofeedback / neuromodulation

Page 17: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic• Idiopathic

• Atrophy

Page 18: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

MSCO

MSCO MSCO

High pressure

Low flow

Page 19: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 20: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 21: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Rx of Post-op Obstruction

• First 3 months – monitoring vs intervention• May experience improvement• Depends on procedure done

• After 3 months• Improvement unlikely• Definitive treatment

Page 22: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Mid Urethral Sling Loosening(1-2 weeks)

• Local anesthesia

• Open vaginal suture line

• Hook sling with a right-angle clamp

• Spread clamp or downward traction on

the tape will usually loosen it (1-2 cm)

• If the tape is fixed, it can be cut

Page 23: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Sling Incision

• Pull down on Foley and palpate sling

• Inverted U or midline incision

• Begin urethral dissection just proximal to sling

• Isolation of sling in the midline or lateral

• Incision of the sling

Nitti VW, Carlson KV, Blaivas JG, Dmochowski RR, Urology 59:47, 2002

Page 24: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

DS

Page 25: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Sling Incision• Sling should spring

apart

• If not, dissect it from urethra

• +/- urethrolysis

Page 26: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 27: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 28: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 29: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

TVT Intervention Results

N Type Success

Klutke, et al* 17 Midline Incision 100% normal emptying

Rardin, et al** 23 Midline Incision 100% normal emptying Loosening 30% complete resol. irritative sx 70% partial resol. irritative sx

* Recurrent SUI in 6%** Significant recurrent SUI 13%

26% recurrent SUI, but significantly better than prior to TVT

Page 30: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Sling Incision Results

N Type SuccessSUI

Klutke, et al Urology 58:697, 2001

Nitti, et al 19 Midline Incision 84% 17%

Amundsen, et al 32 Various 94% retention 9%

67% UUI

Goldman 14 Midline Incision 93% 21%

Page 31: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Urethrolysis

• Transvaginal• Anterior vaginal wall• Suprameatal

• Retropubic

Page 32: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Transvaginal Urethrolysis

• Inverted U incision

• Lateral dissection superficial to PCV

• Endopelvic fascia perforated & retropubic space entered

Page 33: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Transvaginal Urethrolysis• Sharp and blunt dissection • urethra freed from lateral

attachments & undersurface of the pubic bone

• Index finger placed between pubic bone and urethra

• +/- Martius flap interposition

Page 34: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 35: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 36: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 37: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 38: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 39: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 40: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 41: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Urethrolysis Results N Type Success SUI

Foster & McGuire 48 Transvaginal 65% 0

Nitti & Raz 42 Transvaginal 71% 0

Cross, et al 39 Transvaginal 72% 3%

Goldman, et al 32 Transvaginal 84% 19%

Petrou, et al 32 Suprameatal 67% 3%

Webster & Kreder 15 Retropubic 93% 13%

Petrou & Young12 Retropubic 83% 18%

Carr & Webster 54 Mixed 78% 14%

Page 42: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Retropubic Urethrolysis• Mobilization of urethra by sharp

dissection

• Restore complete mobility to anterior

vaginal wall

• Paravaginal repair

• Interposition of omentum between

urethra and pubic bone

Page 43: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic

• Atrophy

Page 44: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Pdet @ Qmax = 36cm H2O

Qmax = 8 ml/S

Page 45: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

symphysis

urethra

Page 46: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Pdet @ Qmax = 54 cm H2O

Qmax = 2 ml/S,

Page 47: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

symphysis

Prolapsedbladder

Page 48: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic

• Atrophy

Page 49: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

FSFS

pdet@Qmax = 68 cm H20

Qmax = 5 ml/S

Tic

Page 50: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic

• Atrophy

Page 51: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 52: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic• Idiopathic

• Atrophy

Page 53: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

pdet@Qmax = 25 cm H20

Qmax = 0.5 mL/S

Page 54: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Urethral diverticulum

Bladder diverticulum

Urethra

Page 55: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic• Idiopathic

• Atrophy

Page 56: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

JT

JT

pdet@Qmax = 75 cm H20

Qmax = 8 ml/SUrethral obstruction

Page 57: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

stricture

Page 58: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic• Idiopathic

• Atrophy

Page 59: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

pdet@Qmax = 100 cm H20

Qmax = 0.5 mL/S

Page 60: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

stricture

Page 61: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Surgical Rx of Stricture

• Urethral dilation

• Urethrotomy

• Urethroplasty• Ventral flap• Dorsal graft

Page 62: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Buccalgraft

Page 63: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Buccalgraft

Page 64: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic• Idiopathic

• Atrophy

Page 65: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

RSN

pdetmax = 90 cm H20

Qmax = 7 ml/S

Page 66: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

RSN

urethra

diverticula

Page 67: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Functional Urethral Obstruction

• Primary vesical neck

• Neurogenic

• Acquired behavior

Page 68: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

2

Strss

pdet@Qmax = 150 cm H20

Qmax = 1 ml/S

Page 69: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor
Page 70: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Rx Primary Vesical Neck Obstruction

• Alpha adrenergic blockade

• Bladder neck incision

• Bladder neck resection

Page 71: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Functional Urethral Obstruction

• Primary vesical neck

• Neurogenic

• Acquired behavior

Page 72: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

PS

Involuntary detrusor contraction

Involuntary sphincter contraction

Obstruction due to sphincter contraction

Page 73: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

CG

Involuntary detrusor contraction

Involuntary sphincter contraction

Vesical neck obstruction

Page 74: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Functional Urethral Obstruction

• Primary vesical neck

• Neurogenic

• Acquired behavior

Page 75: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Detrusor contractionSphincter contraction

Low, interrupted flow

Obstruction by sphincter

Page 76: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Impaired Detrusor Contractility

• Low flow

• Weak or poorly sustained detrusor contraction

• Pressure flow criteria: – Qmax < 12 ml/s– Pdet@Qmax < 20 cm H2O

Groutz et al, Neurourol Urodyn 19:213,2000

Page 77: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

amb

pdetmax = 10 cm H20)

Qmax = 8 ml/S

Page 78: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Impaired Detrusor Contractility:Etiology

• Neurogenic– Thoracic, lumbar & sacral lesions– Diabetes mellitus

• Myogenic– Primary / idiopathc– Urethral obstruction– Bladder overdistension

• Urethral obstruction• Post-surgical

– Ischemia

Groutz et al, Neurourol Urodyn 19:213,2000

Page 79: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Impaired Detrusor Contractility:Treatment

• Observation• Double voiding• Timed voiding • Intermittent catheterization• ? Medications

– Cholinergic agonists– Alpha adrenergic antagonists

Page 80: Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor

Conclusion• Urethral obstuction not uncommon• Prevalence: 2 - 29% of pts with LUTS• Symptoms – non-specific

–irritative 29%–obstructive 8%–both 63%

• Diagnosis based on p/Q studies• Rx based on underlying cause usually

effective for both voiding and OAB sx


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