Voiding Dysfunction 2009

Block lecture, 5th year student.

Choosak Pripatnanont, Department of Surgery, PSU.

Objectives

• Understand and explain physiologic function and dysfunction of lower urinary tract.

• Evaluation patient with LUTS

• Primary management /investigation

• Give primary management of BPH

Storage phase

Emptying phase

Bladder

pressure

Storage phase

Micturition cycle

Detrusorrelaxes

+

Urethracontracts

+Pelvic floorcontracts

Bladder filling

Normal desire to voidDetrusorcontracts

+

Urethra relaxes

+Pelvic floorrelaxes

MICTURITION

First sensation

to voidDetrusorrelaxes

+Urethra

contractionincreases

+Pelvic floorcontracts

First sensation

to voidDetrusorrelaxes

+Urethra

contractionincreases

+Pelvic floorcontracts

Bladder filling

Detrusorrelaxes

+

Urethracontracts

+Pelvic floorcontracts

Bladder filling

Detrusorrelaxes

+

Urethracontracts

+Pelvic floorcontracts

Normal desire to voidDetrusorcontracts

+

Urethra relaxes

+Pelvic floorrelaxes

MICTURITION

Normal voiding

Bladder filling and urine storage require:

1. Accommodation of increasing volumes of urine at a low intravesical pressureand with appropriate sensation.

2. A bladder outlet that is closed at rest and during increases in intra-abdominal pressure.

3. Absence of involuntary bladder contractions.

Bladder emptying requires:

1. A coordinated contraction of the bladder smooth musculature of adequate magnitude.

2. A concomitant lowering of resistance at the level of the smooth and striated sphincter.

3. Absence of anatomic (as opposed to functional) obstruction.

Normal voiding

Functional classification of voiding dysfunction

Failure to store

• Because of the bladder

• Because of the outlet

Failure to empty

• Because of the bladder

• Because of the outlet

Symptomatology:

Irritative bladder symptom: storage symptom

Suprapubic areaPain

the ultimate sign of storage failure, associated with urgency, frequency, or nocturia

Time per day, pads per day

Stress, total, overflow

Incontinence

infection, BOO, or neurogenicbladder.

Time per day, degree of leakage

Urgency

Infection, Insomnia, infection, drinking before bed.

how many times the patient awakes from sleep to urinate

Nocturia

functionally reduced bladder capacity, infection, tumor, stone, outlet obstruction, neurogenicbladder, or foreign body

how many hours between voiding

Frequency

Causes How to measureSymptom

Symptomatology:Obstructive symptoms

Residual urine (cath, ultrasound)Feeling of incomplete emptying

DiscomfortTerminal dribbling

BPH, BOO, CBN, stricture urethra, prostate cancer

Cath.cc.Acute urinary retention

UTI, urethritisDiscomfort ,burning in urethraDysuria

Flowmetry (instrument)Poor stream

Discomfort Straining to void

BPH, BOO, CBN, stricture urethra, prostate cancer

Seconds, IPSShesitancy

Causes How to measureSymptom

Different type of incontinence

Differential diagnosis of voiding dysfunction

Overactive bladder dysfunctionOther

Diuretics, sympathomimetics, anticholinergic, decongestants.Pharmacological

Polydipsia, excessive alcohol or caffeine consumption.Behavioral

Ureteral and bladder stoneAnatomical

Post prostatectomy, Cystectomy, traumatic stricture, radiation cystitis.

Iatrogenic

Poorly controlled DM, Diabetes Insipidus, CHF, hypercalcemia, Obstructive sleep apnea.

Medical

Spinal cord injury, cauda equina syndrome, Parkinsonism, Diabetic autonomic neuropathy, Multiple sclerosis, Alzheimer disease.

Neurologic

Prostatitis, Urethritis, STDInfections

Adenocarcinoma of prostate ,TCC of Bladder ,Squamous cell CA of Penis

Malignant disease

Cause of LUTSCondition

Diseases usually cause voiding dysfunction

pediatrics or congenital voiding dysfunction:

• posterior urethral valve

• phimosis ?

• meatal stricture

• fistula ; ectopic ureteralopening, hypospadias,

Hypospadias

• The most common form of infection found in female.

• Caused by gram-negative bacteria colonized in vaginal introitus.

• Symptoms : irritative bladder dysfunction

• Simple bacterial cystitis is always easy to treat with oral form antibiotic

Cystitisdisease usually cause voiding dysfunction

Type of cystitiswhen investigation needed.

• simple bacterial cystitisrecurrent cystitis

unresolved cystitispersistent cystitishoneymoon cystitis

• complicated cystitisanatomic abnormalities : post RT, contracted bladder, stricture

urethraphysiologic disorder: neurogenic, DMrare type bacteria; TB, granulamatousinterstitial cystitisstone hemorrhagic cystitis

Lower UTI in the male

less common than female, ascending infection usually end up as :

• urethritis

• orchitis

• epididymo-orchitis

• prostatitis

Cystitis is uncommon in male!!

Overactive bladder (OAB)detrusor overactivity (DO)

• Urgency with or without incontinence

• Frequency with low volume of urine

• Psychological and emotional involvement

• Normal urine analysis without pyuria and bacteriuria

Neurogenic bladder

Hyperreflexic bladder dysfunction.

CVA , high cord lesion, Pakinsonism etc.

voiding with reflex activity

irritative bladder dysfunction

low residual urine

urinary dribbling, wettingHyporeflexic bladder dysfunction

Sacral cord lesion, DM with neuropathy, myelomeningocoel

no reflex voiding activity

high residual urine ,

recurrence infection

overflow incontinence

Drugs to Facilitate Storage

Drugs to Facilitate Storage: Decrease Bladder Contractility

PropanthelineOxybutyninTolterodine tartrateFlavoxate (Urispas) Trospium (Sanctura) is a balanced M3/M2 selective anticholinergic.Darifenacin (Enablex) is an M3 selective anticholinergic..Solifenacin (VESIcare) is an antimuscarinic with smooth muscle relaxing

properties.Imipramine : dosage: 25 mg PO tid/qid.Hyoscyamine sulfate

Increase Outlet ResistanceEphedrine Estrogens

Drugs to Facilitate Emptying

Increase Bladder ContractilityBethanechol chloride (Urecholine)

Decrease Outlet ResistancePhenoxybenzamine (Dibenzyline) Prazosin (Minipress) Terazosin (Hytrin) Doxazosin (Cardura) Tamsulosin (Flomax) Alfuzosin (Xatral)

Bladder outlet obstructionBPH is the most common disease

Microscopic BPH : histologic evidence of cellular proliferation of the prostate.

Macroscopic BPH : enlargement of the prostate resulting from microscopic BPH.

Clinical BPH : the LUTS, bladder dysfunction, hematuria, and UTI resulting from macroscopic BPH.

Abrams (1994) has suggested using the more clinically descriptive terms benign prostaticenlargement (BPE), BOO, and LUTS to replace BPH.

Histologic BPH

Clinical BPH (with LUTS)

Not all LUTS is BPHLUTS is not disease specific

Diagnostic test: symptom score

Digital rectal examination (DRE)

• Size

• Consistency:

slight pressure over the surface to detect whether:

– smooth or elastic – normal

– hard or woody – may indicate cancer

– tender – suggests prostatitis

• Mobility: A malignant gland may be fixed to adjacent tissue

• Anatomical limits: seminal vesicles should be impalpable; induration of these suggests malignancy

Kirby R et al (Eds). Shared Care for Prostatic Diseases 1995

Lab test

• urinalysis, should be normal

• PSA, screen or not screen?

-may be unnecessary for pts less than 10 yrs. life expectancy.

-must accompany DRE

-beware of confounding

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DRE suspectedDRE positiveDRE negativeage range, yrs

Objective measure of urine flow rate, Uroflowmetry : Qmax

Treatment goals for LUTS/BPHin clinical practice

Primary goals :

• Fast symptomatic relief of bothering LUTS.

• Improvement in quality of life (QoL).

• Potentially an increase of maximum flow rate (Qmax)

Secondary goals :

• Reducing in long-term worsening of symptoms.

• Preventing serious complication : AUR

Treatment of BPH

Watchful waitng : suitable for• mildly symptomatic

• not bothersome

• laboratory test is normal

• patient choose not to treatment

Medical treatment :• Moderate symptoms and patient agree to treat.

Surgical treatment• Severe symptom , failure medical treatment

• AUR

Drug use for possible shrinkage of prostate 5 alpha reductase inhibitor (Finasteride)

Drugs use for symptomatic relieve of LUTSalpha 1 blocker

• Doxazosin,

• Tamsulosin,

• Alfuzosin,

• Terazosin

Medical treatment

BPH – a progressive condition

Progression of BPH can be defined in

• increase in prostate volume

• worsening of LUTS, bother, interference with daily activities and quality of life

• deterioration in urinary flow rate

• increased risk of acute urinary retention (AUR)

• increased risk of surgery

Patterns of prostate growth (untreated BPH) (PLESS study)

Patterns of prostate growth (untreated BPH) (PLESS study)

McConnell JD et al. N Engl J Med 1998; 38: 557–63

BaselineYears

Prostate volume (mean % change from baseline)

20

10

–20

0

–10

1 2 3 4

Risk factors for acute urinary retention. J Urol 1997;158:481-487.

Current indications for surgery

• Fail medical treatment

• AUR

• Problems with compliance

• Side effect from medication

• Progressive enlargement of prostate

• Hematuria

Objectives, Do you copy?

• Understand and explain physiologic function and dysfunction of lower urinary tract.

• Evaluation patient with LUTS

• Primary management /investigation

• Give primary management of BPH