1. Bladder outlet obstruction (BOO) in women Ingrid Nygaard, MD, MS Professor University of Utah

2. 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.

3. 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

4. Symptoms of BOO are common in women Amongst 297 women, mean age 68, not seeking care: – Frequency29% – Urgency29% – Difficulty emptying13% – Incomplete emptying21% – Weak stream19% – Intermittent stream26% – Postvoid dribble7% (Reported that symptom occurred ‘usually’ during past 3 months.) Bradley, Kennedy, Nygaard 2005

5. Symptoms of BOO are common WeeklyDaily Hesitancy28%16% Straining15%8% Incomplete emptying16%7% Post void dribble14%4% 4,000 Danish women 3/4 had symptom “sometimes” MØLLER, LOSE, JØRGENSEN. Acta Obstet Gynecol Scand 2000

6. Given that symptoms are common, how well do they correlate with ‘objective’ evidence of obstruction?

7. Predictive value of obstructive voiding symptoms and tests In 95 women visiting urogyn clinic for LUTS: Positive responsePositive Predictive Value (compared to PVR > 50 ml) “Do you usually experience feeling of incomplete bladder emptying?” 47%0.16 Max flow < 10 th %34%0.29 Low flow and high pressure during voiding 20%0.28 [Jeon and Yoo, 2012]

8. 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]

9. 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.

10. 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”)

11. 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 symptoms Bradley, Kennedy, Nygaard 2005

12. Overactive outlet Medications that increase resistance – Alpha adrenergic agonists (phenylpropanolamine) – SSRI (duloxetine) – Beta adrenergic antagonists (propranol)

13. SUI surgery and subsequent BOO (UITN studies) New UUIVoiding 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

14. Treatment of BOO following mid- urethral sling When? Where? How? NB: STEP 1: Ensure patient is not straining to void!

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. BOO due to anatomic obstruction Pelvic Organ Prolapse (POP) POP-Q stagePVR* 025 (0-270) [median, range] 130 (0-250) 245 (0-700) 3,450 (0-350) *cath, 5 min post void Cetinkaya et al, 2013

22. Women with POP and SUI have more bladder symptoms Stress Continent Stress Incontinent OR (95% CI) No. women29682 % with bothersome symptoms Irritative47%80%0.22 (0.11–0.42) Nocturia31%55%0.35 (0.20–0.62) Enuresis0.3% 8%0.05 (0.00–0.55) Dysuria12%20%0.67 (0.32–1.40) Voiding49%72%0.36 (0.20–0.66) PVR87 ml66 ml Irritative and obstructive symptoms, and bother Richter, Nygaard et al. J Urol 2007

23. ↑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]

24. 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

25. Is urethral stricture treated by urethral dilation? Or Does urethral dilation cause urethral stricture?

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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.

32. BOO and storage symptoms (“OAB”) Pubmed search: “bladder outlet obstruction” and “overactive bladder” 1/50 studies are not about men or rats.

33. Outlet obstruction Altered receptor function, myogenic denervation, imbalance of neurotransmitters Detrusor Overactivity

34. 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

35. TOMUS RetropubicTransobturator Change UDI irritative-31-33 Change UDI obstructive-15 New urge incontinence by 6 weeks 0/2981/299 Persistent urge incontinence at 6 weeks 12%10% Persistent urgency14%13% Richter, Albo et al. NEJM 2010

36. 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

37. 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