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
Urethral Obstruction in Women Prevalence: % of women with persistent LUTS Symptoms: – storage 29% – emptying 8% – both 63%
Diagnosis Urodynamics (synchronous pdet / Q) Cystoscopy
Urethral obstruction High detrusor pressure (pdet > 20 cm H 2 0) Low uroflow (Qmax < 12 ml/S)
Impaired Detrusor Contractility Weak & or poorly sustained detrusor contraction (pdet < 20 cm H 2 0) Low flow (Qmax < 12 ml/S)
Blaivas - Groutz Nomogram
Diagnosis ”…radiographic evidence of obstruction…in the presence of a sustained detrusor contraction.” No specific UDS criteria Obstructed women had: –lower Qmax –higher –higher PVR 23% of 331 women were obstructed Nitti et al., 1999:
Etiology Groutz et al., 2000; Nitti et al., 1999 Prior surgery % Prolapse 29% Stricture 15% 1 O bladder neck obstruction % DESD 6% Learned Voiding Dysfunction % Urethral diverticulum 4%
Urethral Obstruction in women Anatomic Functional
Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy
Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior
Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy
MSCO High pressure Low flow
Blaivas - Groutz Nomogram
Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy
Qmax = 36cm H2O Qmax = 8.3ml/S
Blaivas - Groutz Nomogram
Qmax = 54 cm H2O Qmax = 2 ml/S,
Blaivas - Groutz Nomogram
Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy
FS = 68 cm H 2 0 Qmax = 5 ml/S Tic
Blaivas - Groutz Nomogram
Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy
Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy
JTJT JT = 80 cm H 2 0 Qmax = 5 ml/S
Blaivas - Groutz Nomogram
Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy
JTJT JT = 75 cm H 2 0 Qmax = 8 ml/S Urethral obstruction
Blaivas - Groutz Nomogram
Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy
Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy
RSN pdetmax = 90 cm H 2 0 Qmax = 7 ml/S
Blaivas - Groutz Nomogram
Anatomic Urethral Obstruction: Treatment Intermittent catheterization Surgery - depends on the cau se: –correct prolapse –sling incision / urethrolysis –urethral diverticulectomy
Surgical Rx of Stricture Urethral dilation Urethrotomy Urethroplasty
Buccal graft
Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior
2 Strss = 150 cm H20 Qmax = 1 ml/S
Blaivas - Groutz Nomogram
Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior
PS Involuntary detrusor contraction Involuntary sphincter contraction Obstruction due to sphincter contraction
CG Involuntary detrusor contraction Involuntary sphincter contraction Vesical neck obstruction
Blaivas - Groutz Nomogram
Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior
Detrusor contraction Sphincter contraction Low flow Obstruction by sphincter
Functional Urethral Obstruction: Treatment Primary vesical neck TUI / TUR of vesical neck ? Alpha adrenergic antagonists Neurogenic Intermittent catheterization +/- anticholinergics, Botox, Neuromodulation, enterocystoplasty Acquired behavior Bmod / biofeedback
Impaired Detrusor Contractility Low flow Weak or poorly sustained detrusor contraction Pressure flow criteria: –Qmax < 12 ml/s < 20 cm H2O –Wmax < 10 Groutz et al., 2000
amb pdetmax = 10 cm H 2 0) Qmax = 8 ml/S
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., 2000
Impaired Detrusor Contractility: Treatment Observation Double voiding Timed voiding Intermittent catheterization ? Medications –Cholinergic agonists –Alpha adrenergic antagonists Neuromodulation
Conclusion Urethral obstuction not uncommon Prevalence: % of pts with LUTS Symptoms – non-specific –irritative 29% –obstructive 8% –both 63% Diagnosis based on p/Q studies Rx based on underlying cause