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排尿障礙治療中心 版權所有
Bladder Outlet Obstructionin Women
Hann-Chorng KuoDepartment of Urology
Buddhist Tzu Chi General Hospital
排尿障礙治療中心 版權所有
Causes of Obstructive LUTS in Women
• Bladder hypersensitivity• Poor relaxation of pelvic floor muscles• Spastic urethral sphincter • Bladder neck dysfunction• Urethral stricture• External compression• Prolapse of uterus
排尿障礙治療中心 版權所有
Bladder outlet obstruction in women
• Diagnosis of BOO in women is often overlooked
• Incidence of BOO is about 2.7 – 23%• Anatomical and functional cause of BO
O contributed equally• Detrusor instability coexists with BOO• Patients may present with storage LUT
S
排尿障礙治療中心 版權所有
Criteria for Female BOO
• Massey & Abrams: PdetQmax>50 cm water and Qmax <12 ml/s
• Axelrod & Blaivas: sustained PdetQmax >20 cm water and Qmax <12 ml/s
• Chassagne et al: PdetQmax>20 cm water and Qmax <15 ml/s
• Nitti: VUDS proven obstructed outlet, high pressure, low flow, large residuum
排尿障礙治療中心 版權所有
Incidence of BOO in Women
Approximately in 2.7% to 8% in the women with LUTS undergoing urodynamics
• Chassagne ( 1998 ): 35/159 ( 22% ) with Qmax <15ml/s and Pdet.Qmax >20cmH2O
• Nitti ( 1999 ): 76/331 ( 23% ) with radiographic urethral narrowing and reduced flow
• Groutz ( 2000 ): 38/587 ( 6.5% ) with Qmax <12ml/s and Pdet.Qmax >20cmH2O
排尿障礙治療中心 版權所有
Etiologies of BOO in Women• Previous anti-incontinence surgery 20%• Severe genital prolapse 16%• Severe prolapse and surgery 4%• Urethral stricture or narrowing 18%• Primary bladder neck obstruction 6%• Urethral diverticulum 6%• Learned voiding dysfunction 4%• Detrusor external sphincter dyssynergia 4%• Idiopathic 22%
排尿障礙治療中心 版權所有
Bladder Neck Dysfunction
• No definite scarring tissue• Persistent narrowing of bladder neck
during voiding• Trabeculation of bladder wall• Bilateral hydronephrosis may occur• Alpha-blocker or TUI-BN is effective• Recurrence of obstruction is possible
排尿障礙治療中心 版權所有
Bladder neck dysfunction in woman
排尿障礙治療中心 版權所有
Urethral stricture in woman• Definite urethral scarring can be found in cys
tourethroscopy or urethrogram• History of indwelling Foley catheter or trans
urethral surgery• Obstructive type low flow rate• Coordinated urethral sphincter EMG during v
oiding phase• Relief of obstructive symptom after urethral
dilatation• Medication are not always effective
排尿障礙治療中心 版權所有
Urethral Stricture
排尿障礙治療中心 版權所有
Dysfunctional voiding in woman
• Spastic urethral sphincter as etiology• Learned habit?• May present with frequency urgency d
ysuria and/or urge incontinence• Cystourethrography revealed spinnin
g top appearance• Patient may have bilateral VU reflux o
r recurrent UTI
排尿障礙治療中心 版權所有
Spastic urethral sphincter (Dysfunctional voiding)
排尿障礙治療中心 版權所有
External compression of urethra• Infrequent cause of bladder outlet obstructi
on in women• Prolapse of uterus or uterine tumor compre
ssion of the urethra and bladder neck, imperforated hymen
• May present with severe dysuria and large residual urine or urine retention
• Physical examination or cystoscopy may aid in diagnosis
排尿障礙治療中心 版權所有
Iatrogenic bladder outlet obstruction
• Anti-incontinence surgery or anterior colporrhaphy – transvaginal or transabdominal surgery may occur
• Severe frequency, urgency, and dysuria developed after anti-incontinence surgery
• A low flow rate with large residual urine• Elevated bladder neck and angulated ureth
rovesical angle
排尿障礙治療中心 版權所有
Iatrogenic urethral obstruction
排尿障礙治療中心 版權所有
Detrusor instability developed after Bladder neck suspension
排尿障礙治療中心 版權所有
Uterine prolapse and Cystocele• Gr 5 cystocele and uterine prolapse ca
use angulation of urethrovesical angle• Patient always uses manual reduction
of bladder to void• Large residual urine and low flow rate• May mask intrinsic sphincter deficienc
y during leak point pressure measurement
排尿障礙治療中心 版權所有
Cystocele and Uterine Prolapse
排尿障礙治療中心 版權所有
Uterine prolapse and BOO
排尿障礙治療中心 版權所有
Reduction of cystocele relieves BOO
排尿障礙治療中心 版權所有
Obstructive uropathy in prolapse
排尿障礙治療中心 版權所有
Urethral meatal stenosis
排尿障礙治療中心 版權所有
Comparison of Qmax in BOO and non-BOO women
排尿障礙治療中心 版權所有
Comparison of detrusor pressure in BOO and non-BOO women
排尿障礙治療中心 版權所有
Nomogram for Female BOO
排尿障礙治療中心 版權所有
Blaivas BOO nomogram
排尿障礙治療中心 版權所有
Medical Treatment for Female BOO
• Skeletal muscle relaxant – diazepam, baclofen, dantrolene, calcium blocker
• Alpha-adrenergic blocker – dibenylene, terazosin, doxazosin, tamsulosin
• Nitric oxide donor- nitroglycerine, isosorbid mononitrate
• Estrogen• Botulinum A toxin
排尿障礙治療中心 版權所有
Surgical Treatment for Female BOO
• Transurethral incision of bladder neck• Urethral dilatation• Transurethral sphincterotomy• Meatotomy• Transvaginal urethrolysis
排尿障礙治療中心 版權所有
Isolated urethral sphincter obstruction in detrusor areflexia
排尿障礙治療中心 版權所有
Botulinum A toxin sphincter injection• Botulinum A toxin is an inhibitor of acetylch
oline release at the presynaptic neuromuscular junction
• Inhibition of acetylcholine release results in regional decreased muscle contractility at the injection site
• This chemical devervation is a reversible process, axons resprout in about 3-6 months
排尿障礙治療中心 版權所有
Clinical application of botulinum A toxin in voiding dysfunction• Botulinum A toxin 20-80 units successfully treated 11 SCI
& DESD (Dykstra et al 1988)• In 21 of 24 SCI & DESD, BTX-A toxin 100 IU reduced residu
al urine and MUCP (Schurch 1996)• Transperineal injection of BTX-A in 6 SCI improved voidi
ng function (Schurch et al 1997)• Improved bladder capacity and decreased maximal detr
usor pressure after BTX-A in 5 SCI (Gallien et al 1998)• Relief of voiding dysfunction due to prostatitis in 4 men
(Maria et al 1998)• Effective in treating DESD (12), pelvic floor spasticity (8),
and acontractile detrusor (1) by BTX-A 80-100 IU (Michael et al 2001)
排尿障礙治療中心 版權所有
Botulinum A toxin therapy• 100 units (1vial) is diluted to 2ml• 50 units will be used in the first trial, 4 equiv
alent aliquot are injected via cystoscopy guide in men and around the urethra in women
• Complete cardiorespiratory monitoring in OR
• Foley catheter is indwelled for 1 day• Report adverse effect (AD, hematuria, UTI)
排尿障礙治療中心 版權所有
Botulinum A toxin injection in women
排尿障礙治療中心 版權所有
Botulinum A toxin injection in Spinal cord injured woman with DESD
排尿障礙治療中心 版權所有
Reduction of MUCP after Botulinum A toxin injection
排尿障礙治療中心 版權所有
Urethral Injection of Botulinum A toxin for Female BOO
排尿障礙治療中心 版權所有
Transurethral incision of urethral sphincter• Total incontinence after sphincterotomy• Indicated in quadriplegia women with adeq
uate detrusor contractility and DESD, recurrent UTI or upper tract deterioration
• Crede maneuver may be indicated• Irreversible procedure, should be performe
d with adequate informed consent• Botulinum toxin injection maybe another al
ternative
排尿障礙治療中心 版權所有
Detrusor instability and Female BOO• In women with frequency urgency an
d urge incontinence, detrusor instability may be due to BOO
• Idiopathic DI may be occult neuropathy in young women, such as multiple sclerosis
• Dysfunctional voiding should also be considered
排尿障礙治療中心 版權所有
Dysfunctional voiding and bilateral VUR in a woman with incontinence
排尿障礙治療中心 版權所有
Screening of BOO in Women with LUTS• Patient with urge incontinence after an
ti-incontinence surgery• Urge incontinence associated with dysu
ria, refractory to medication• A low maximal flow rate with plateau fl
ow pattern,nor respond to medication• Elderly women with frequency & dysuri
a• Previous catherization and LUTS
排尿障礙治療中心 版權所有
Videourodynamic Findings in Female Bladder Outlet Obstruction• Presence of spontaneous DI• High voiding pressure and low flow rat
e• Moderate to large residual urine• Bladder neck narrowing or urethral nar
rowing (mid-urethra or distal urethra)• Coordinated EMG (stricture) or discoor
dinated EMG (dysfunctional voiding)
排尿障礙治療中心 版權所有
Dysfunctional voiding in a woman
排尿障礙治療中心 版權所有
Obstructive Uropathy due to Chronic Bladder Distension
排尿障礙治療中心 版權所有
Cystoscopic Findings in Bladder neck dysfunction
排尿障礙治療中心 版權所有
Appearance of Bladder neck after TUI-Bladder neck
排尿障礙治療中心 版權所有
Video Urodynamic results before and after TUI-Bladder neck
排尿障礙治療中心 版權所有
Resolution of hydronephrosis
排尿障礙治療中心 版權所有
Postoperative uroflowmetry and renalsonography
排尿障礙治療中心 版權所有
Diagnosis of BOO in Women
• Alert in evaluation of LUTS in women• Do uroflowmetry and cystoscopy in w
omen refractory to medication• Pressure flow study in women with tra
beculated bladder and large residual urine
• When bilateral hydronephrosis is found, always consider bladder outlet origin