Female Urology MANAGEMENT OF FUNCTIONAL BLADDER NECK OBSTRUCTION IN WOMEN: USE OF -BLOCKERS AND PEDIATRIC RESECTOSCOPE FOR BLADDER NECK INCISION

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1 /99/ /0 THE JOURNAL OF UROLOGY Vol. 162, , December 1999 Copyright 1999 by AMERICAN UROLOGICAL ASSOCIATION, INC. Printed in U.S.A. Female Urology MANAGEMENT OF FUNCTIONAL BLADDER NECK OBSTRUCTION IN WOMEN: USE OF -BLOCKERS AND PEDIATRIC RESECTOSCOPE FOR BLADDER NECK INCISION ANANT KUMAR, ANIL MANDHANI, SANJAY GOGOI AND ANEESH SRIVASTAVA From the Department of Urology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India ABSTRACT Purpose: Functional bladder neck obstruction has been definitively diagnosed in the last few years due to detailed synchronous pressure flow, electromyography and video urodynamics. Clean intermittent self-catheterization and bladder neck incision are the modalities of treatment. To our knowledge the role of -blockers is not yet defined in women. A new technique was developed to perform bladder neck incision using a pediatric resectoscope. Materials and Methods: A total of 24 women with obstructive voiding symptoms or retention were evaluated with video pressure flow electromyography, and diagnosed with functional bladder neck obstruction due to high pressure and low flow on silent electromyography and bladder neck appearance on fluoroscopy. Patients were initially treated with clean intermittent self-catheterization and -blockers. was stopped when post-void residual was less than 50 ml. and only -blocker therapy was continued. Bladder neck incision was performed in patients who had a poor response to or side effects of -blocker therapy, or when therapy was discontinued due to economic reasons. Clean intermittent self-catheterization was continued in patients who had a poor response to -blockers or refused to undergo bladder neck incision. Bladder neck incision was performed in the initial 2 cases with an adult resectoscope using a Collin s knife and subsequently a pediatric resectoscope (13F). Uroflow and post-void residual measurements were performed in all cases. Results: Of the 24 patients 12 (50%) showed improvement in symptoms, peak flow and post-void residual (p 0.01) with -blocker therapy only. Of the 12 patients who had a poor response to -blockers 6 underwent bladder neck incision subsequently and 6 remained on clean intermittent self-catheterization. All 8 patients treated with bladder neck incision, including 2 who had a good response but discontinued -blocker therapy, had sustained improvement in post-void residual and peak flow (p 0.01) after a mean followup of years. Grade 1 stress incontinence in 2 adult resectoscope cases responded to conservative treatment. None of the pediatric resectoscope cases had stress incontinence. Conclusions: Clean intermittent self-catheterization and -blockers are the initial treatment options for functional bladder neck obstruction. The -blockers were successful in 50% of our patients. Bladder neck incision should be offered judiciously with minimal risk of curable stress incontinence. The pediatric resectoscope is useful to make a well controlled incision safely in the female urethra. KEY WORDS: bladder neck obstruction, adrenergic alpha-antagonists Functional bladder neck obstruction in women remains a poorly understood and improperly diagnosed clinical entity. These cases usually remain undiagnosed and are treated as the urethral syndrome, lazy bladder or nonneurogenic neurogenic bladder. In the last few years functional bladder neck obstruction has been definitively diagnosed using detailed synchronous pressure flow, electromyography and video urodynamics. Functional bladder neck obstruction may be a progressive clinical disorder leading to end stage renal failure if not corrected at an appropriate time. 1 3 The role of -blockers in treating functional bladder neck obstruction is established in men. Bladder neck incision is a Accepted for publication June 18, treatment option in a subgroup of patients with good results. In the small female urethra the use of an adult resectoscope frequently results in difficulty making a well controlled incision as the resectoscope tends to come out of the urethra. This problem can be overcome by using a pediatric resectoscope. We present a retrospective analysis of treatment of functional bladder neck obstruction in women, highlighting the use of a pediatric resectoscope for bladder neck incision and -blocker therapy. MATERIALS AND METHODS From January 1988 to December 1997 urodynamic data of all women with a diagnosis of functional bladder neck ob-

2 2062 MANAGEMENT OF FEMALE BLADDER NECK OBSTRUCTION struction were reviewed. Criteria for the diagnosis of functional bladder neck obstruction are listed in the Appendix. All patients who had an anatomical cause or systemic disease (for example cerebrovascular disease, diabetes mellitus, neurological lesions and so forth) known to affect lower urinary tract function, and those with a history of drug intake which could affect voiding were excluded from study. A total of 25 patients met the study criteria. Patients underwent uroflowmetry to evaluate maximum and average flow rates. Those who had acute or chronic urinary retention were initially treated with an indwelling urethral catheter for 2 weeks before urodynamic study. A repeat study was done after 6 to 8 weeks. A 6F infant feeding tube was used to fill the bladder and a 5F epidural catheter was placed suprapubically to record intravesical pressure. A rectal tube was used to measure abdominal pressure. Electromyography of the sphincteric region was monitored by inserting a bipolar needle (49 mm.) in the periurethral or perirectal region. Normal saline mixed with 2 or 3 ampules of sodium or meglumine diatrizoate was used as a filling medium. The patient sat on a chair while bladder neck and external sphincter urodynamics were monitored simultaneously using C-arm fluoroscopy. High pressure, poor flow and silent sphincter during voiding with inadequate opening of the bladder neck were considered diagnostic of functional bladder neck obstruction. 1 3 Initially all patients were treated with -blockers. Phenoxybenzamine, prazosin or terazosin was prescribed at different times per availability in the country. Presently we are only prescribing terazosin. All patients were advised to monitor residual urine after voiding. With a significant decrease in residual, clean intermittent self-catheterization was stopped and -blocker treatment was continued. Patients who had severe side effects or a poor response to -blockers, or who discontinued therapy due to economic constraints were treated with bladder neck incision or clean intermittent self-catheterization alone. In the initial 2 cases bladder neck incision was made with an adult resectoscope and in the subsequent 6 with a 13F pediatric resectoscope. A Collin s knife and 40 W. cutting current were used. A single incision was made at the 12 o clock position from 2 mm. proximal to the bladder neck to the mid urethra but no attempt was made to see fat. Patients were catheterized after the procedure and a voiding trial was done after 48 hours. Outcomes were assessed by uroflowmetry, post-void residual and urodynamic study. Statistical analysis was done by the matched paired Wilcoxon signed rank test. TABLE 1. Demographics of patients presenting with symptoms Total pts. 24 Mean age SD followup (%): Obstructive voiding symptoms 24 (100) Retention 6 (26) Renal failure 6 (25) Urinary tract infection 12 (50) High post-void residual 12 (50) TABLE 2. Results at last followup RESULTS -Blocker Therapy Bladder Neck Incision pts Mean max. flow rate SD (ml./sec.): Before treatment After treatment Mean post-void residual SD (ml.): Before treatment After treatment For all comparisons p A total of 24 women 19 to 65 years old (mean age years) met the urodynamic criteria for functional bladder neck obstruction (see Appendix and fig. 1). 1 3 Followup ranged from 4 months to 10 years (mean months). All patients had had predominantly obstructive urinary symptoms for 4 months to 20 years (average years) (table 1). Of 24 women 6 (25%) had acute or chronic renal failure (serum creatinine more than 2.0 mg.). All women recovered completely with catheter drainage. Mean maximum detrusor pressure was cm. water (range 40 to 190) and mean maximum flow rate in 18 patients (6 could not void) was ml. per second at initial presentation. Post-void residual ranged from 31 to 900 ml. (mean ). Clean intermittent self-catheterization and -blockers were prescribed in all patients once the diagnosis was established. Different -blockers were prescribed at different times per availability in the country. A dose of 10 to 15 mg. phenoxybenzamine daily was administered from 1988 to 1991, 1 to 4 mg. prazosin daily from 1992 to 1996 and 2 to 5 mg. terazosin daily from 1997 to Patients were asked to monitor post-void residual. Once there was a significant decrease in post-void residual, clean intermittent self-catheterization was stopped and -blockers were continued. These patients were advised to keep checking post-void residual once a week and to reinstitute clean intermittent self-catheterization if there were more than 100 ml. Of the patients 12 responded to -blocker therapy. Symptoms improved, peak flow increased and post-void residual decreased significantly (table 2 and fig. 2). However, 1 patient opted for bladder neck incision due to intolerable side effects and another for economic reasons. In 12 patients the response to -blockers was inadequate even after 6 weeks of treatment, and so therapy was discontinued. The 6 patients who underwent bladder neck incision showed dramatic improvement in symptoms, peak flow and post-void residual (tables 3 to 5 and fig. 2). There were 6 patients who did not opt for bladder neck incision and preferred to practice clean intermittent self-catheterization. In 2 adult resectoscope cases mild stress urinary incontinence responded to conservative treatment. In the other 6 pediatric resectoscope cases there were no complications. All patients were voiding well at last followup. FIG. 1. Characteristic diagnostic findings of functional bladder neck obstruction case with high detrusor pressure (Pdet), low peak flow and relaxed sphincter. Qura, peak uroflow. Pabd, abdominal pressure. Pves, bladder pressure. EMGave, average electromyography of pelvic floor. DISCUSSION Less than 1% of all women with voiding complaints are diagnosed with functional bladder neck obstruction. 4, 5 These patients have symptoms of long duration which vary from

3 MANAGEMENT OF FEMALE BLADDER NECK OBSTRUCTION 2063 FIG. 2. Peak flow (Qmax) in -blocker (A) and bladder neck incision (B) groups before (Pre t/t) and after (Post t/t) treatment (p 0.01) TABLE 3. Urodynamic data before and after each -blocker therapy Max. Flow Rate (ml./sec.) Detrusor Pressure at Peak Flow Post-Void Residual (ml.) After -Blockers * (cm. water) After -Blockers Mean SD *No -blocker therapy. Max. Flow Rate (ml./sec.) TABLE 4. Urodynamic data before and after bladder neck incision After Bladder Neck Incision Detrusor Pressure at Peak Flow (cm. water) Post-Void Residual (ml.) After Bladder Neck Incision Treatment Modality Blockers bladder neck incision Blockers bladder neck incision Bladder neck incision Bladder neck incision Bladder neck incision Bladder neck incision Bladder neck incision Bladder neck incision Mean SD obstruction to irritative voiding. The exact etiology of this entity remains unclear and has been attributed to detrusor bladder neck dyssynergia, bladder neck hypertrophy secondary to distal urethral obstruction and/or fibrosis of the bladder neck. 4 Some of our patients presented with renal failure and had prolonged history of obstructive voiding symptoms. All patients responded well and achieved normal creatinine in due course. Simultaneous measurement of detrusor pressure, flow rate electromyography and fluoroscopic video monitoring during volitional voiding offers the best opportunity for accurate diagnosis of outlet obstruction. 2.3 There is no consensus in regard to a cutoff for detrusor pressure and flow rate that is diagnostic of obstruction. Obstruction exists when a pressure flow study shows low uroflow, despite a detrusor contraction of adequate force and duration, and regardless of numerical value. 6, 7 Voiding pressure of more than 50 cm. water with flow rates less than 15 ml. per second suggests outlet obstruction. 8, 9 Detrusor pressure of 30 to 60 cm. water has also been seen in some patients in many series with bladder outlet obstruction In this series all patients had maximum detrusor pressure of more than 40 cm. water (mean ). Although there is a scarcity of receptors in normal bladder neck smooth muscle and the urethra, altered sensitivity to adrenergic drugs has been noted following parasympathetic denervation and urethral obstruction. 12 The -adrenergic antagonists increase urethral flow rate and reduce residual urine volume in patients with neurogenic bladder or obstruction The -blockers have been used infrequently to treat female bladder neck obstruction. 16 A limited number of clinical trials support the use of -blockers in women. Kawabe and Niijima reported improvement in peak flow and residual

4 2064 MANAGEMENT OF FEMALE BLADDER NECK OBSTRUCTION TABLE 5. Urodynamic data before and after clean intermittent self-catheterization Max. Flow Rate (ml./sec.) Detrusor Pressure at Peak Flow (cm. water) Post-Void Residual (ml.) Not done Not done Not done Not done Not done Not done Not done Not done Not done 198 Mean SD in 80% of cases with an -blocker agent (YM-12617) in 5 patients. 17 All of our patients with functional bladder neck obstruction were initially treated with clean intermittent self-catheterization and -blocker simultaneously. Half of the patients (50%) had symptomatic relief and improvement in peak flow, and clean intermittent self-catheterization was discontinued as postvoid residual was insignificant. Of these 12 patients 2 subsequently underwent bladder neck incision for other reasons. Double-blind prospective trials are required to prove further the efficacy of -blockers in women. The 6 patients who did not show symptomatic improvement with -blocker therapy were kept on clean intermittent self-catheterization alone as they did not elect bladder neck incision and therapy was discontinued. Transurethral bladder neck incision appears to be the preferred treatment with expectation of excellent results. 2, 3 Advantages of the procedure include simplicity, shorter postoperative stay, absence of the need for blood transfusion and a lower complication rate. Bladder neck incision may also be repeated, if there is inadequate response followed by recurrence of symptoms. 18, 19 We have repeated the procedure successfully in 3 women whose symptoms recurred 12 months later. Initial poor results of bladder neck incision in large series were mostly due to decompensated state of the bladder. In 1 study 28.8% of patients required repeat bladder neck incision. 20 All of our patients were doing well at a mean followup of years. Delaere et al performed bladder neck incision in 32 patients who had difficulty emptying and 56% benefited from the procedure. 20 Of the patients 6 underwent repeat incision and 2 had severe postoperative stress incontinence. A large series demonstrated 15.3% incidence of incontinence in the early postoperative period but in 76% of these patients symptoms resolved without further treatment. 21 In our initial 2 adult resectoscope cases stress incontinence responded well to conservative treatment. Subsequently a pediatric resectoscope was used in 6 cases with no adverse outcome. The discrepant sizes of the adult resectoscope and the female urethra lead to a frequent tendency of the resectoscope to slip out of the urethra while the incision is being made. The projected loop is shorter in the pediatric than in the adult resectoscope, and so a precise and well controlled incision at the bladder neck with proper assessment of depth and length can be made (fig. 3). CONCLUSIONS Clean intermittent self-catheterization and -blockers are the initial treatment options for functional bladder neck obstruction. The -blockers are effective in 50% of cases and bladder neck incision should be offered judiciously in select cases. The use of a pediatric resectoscope helps to make a well controlled incision with less chance of stress incontinence. Poor responders to -blocker therapy and patients who are unwilling to undergo bladder neck incision can be relieved of symptoms with clean intermittent self-catheterization alone. FIG. 3. Projected loop is shorter in pediatric than in adult resectoscope, which helps to make well controlled incision in female urethra. APPENDIX: DIAGNOSTIC CRITERIA Less than 10 ml./sec. peak flow Greater than 40 ml./sec. detrusor pressure during voiding Inadequate funneling of bladder neck Greater than 40 cm. water opening pressure Relaxed external sphincter Greater than 100 ml. post-void residual despite high detrusor pressure No associated neurological deficit Normal urethral caliber REFERENCES 1. Kumar, A., Banerjee, G. K., Goel, M. C., Mishra, V. K., Kapoor, R. and Bhandari, M.: Functional bladder neck obstruction: a rare cause of renal failure. J. Urol., 154: 186, Mishra, V. K., Kumar, A., Kapoor, R., Srivastava, A. and Bhandari, M.: Functional bladder neck obstruction in males: a progressive disorder. Eur. Urol., 22: 123, Kumar, A., Mishra, V. K., Kapoor, R., Dalela, D. and Bhandari, M.: Functional bladder neck obstruction in females a revisit. Arch. Esp. Urol., 44: 1209, Axelrod, S. L. and Blaivas, J. G.: Bladder neck obstruction in women. J. Urol., 137: 497, Diokno, A. C., Hollander, J. B. and Bennet, C. J.: Bladder neck obstruction in women: a real entity. J. Urol., 132: 294, Norlen, I. J. and Blaivas, J. G.: Unsuspected proximal urethral obstruction in young and middle-aged men. J. Urol., 135: 972, Gilja, I., Kovacic, M., Radej, M. and Parazajder, J.: Functional obstruction of bladder neck in men. Neurol. Urodyn., 8: 433, Farrar, D. J., Osborne, J. L., Stephenson, T. P., Whiteside, C. G., Weir, J., Berry, J., Milroy, E. J. and Warwick, R. T.: A urodynamic view of bladder outflow obstruction in the female: factors influencing the results of treatment. Brit. J. Urol., 47: 815, Massey, J. A. and Abrams, P. H.: Obstructed voiding in the female. Brit. J. Urol., 61: 36, 1988.

5 MANAGEMENT OF FEMALE BLADDER NECK OBSTRUCTION Mayo, M. E.: Primary bladder neck obstruction in men: variations in detrusor response. J. Urol., 128: 957, Yalla, S. V., Waters, W. B., Snyder, H., Varaday, S. and Blute, R.: Urodynamic localization of isolated bladder neck obstruction in men: studies with micturitional vesicourethal static pressure profile. J. Urol., 125: 677, Koyanagi, T.: Further observation on the denervation supersensitivity of the urethra in patients with chronic neurogenic bladders. J. Urol., 122: 348, Caine, M.: The present role of -adrenergic blockers in the treatment of benign prostatic hyperplasia. J. Urol., 136: 1, Krane, R. J. and Olsson, C. A.: Phenoxybenzamine in neurogenic bladder dysfunction: 1A theory of micturition. J. Urol., 110: 650, Scott, M. B. and Morrow, J. W.: Phenoxybenzamine in neurogenic bladder dysfunction after spinal cord injury. I: Voiding dysfunction. J. Urol., 119: 480, Yoshida, O., Takeuchi, H., Hida, S., Tomoyoshi, T., Arai, Y. and Okada, K.: Clinical efficacy and safety of long-term administration of YM617 for urinary obstruction of lower urinary tract. Hinyokika-Kiyo, 37: 421, Kawabe, K. and Niijima, T.: Use of an -1-blocker, YM-12617, in micturition difficulty. Urol. Int., 42: 280, Choudhury, A.: Incisional treatment of obstruction of the female bladder neck. Ann. R. Coll. Surg. Engl., 60: 404, Fenster, H. N.: Female bladder neck incision. Urology, 35: 109, Delaere, K. P., Debruyne, F. M. and Moonen, W. A.: Bladder neck incision in the female: a hazardous procedure? Brit. J. Urol., 55: 283, Bhatnagar, B. N. and Barnes, R. W.: Incontinence following transurethral resection of bladder neck in females. Brit. J. Urol., 53: 29, EDITORIAL COMMENT The authors present a series of 24 women with functional bladder neck obstruction who were carefully diagnosed with video urodynamics, including external sphincter electromyography. The authors used accepted diagnostic criteria which include high pressure, low flow voiding with silent sphincter activity during voiding and inadequate opening of the bladder neck. They correctly note that there is no consensus in regard to a cutoff for detrusor pressure and flow rate that is diagnostic of obstruction in women. In this series all but 2 cases had elevated voiding pressures and would probably be classified as obstructed even on most nomograms for men. We have used less stringent pressure flow criteria to diagnose obstruction in women. 1 Nevertheless, it appears that all patients in this group clearly were obstructed based on video urodynamic criteria. The authors make a case for using -blockers as an initial treatment for functional bladder neck obstruction in women. They report a 50% success rate with respect to increased flow and decreased post-void residual, and improved symptoms. We have had similar success noting symptomatic improvement in women with primary bladder neck obstruction. In this series most patients had advanced obstruction with elevated post-void residual and required intermittent catheterization. We have seen several patients with less severe degrees of bladder neck obstruction when the main reason for treatment was symptoms and not elevated post-void residual or impairment of renal function. In such patients success is best measured by improvement in symptoms. Unfortunately, in this series validated symptom scores were not used and, thus, it is difficult to measure the actual effect on symptoms, although positive effects on flow rate and post-void residual are clearly documented. The authors also performed bladder neck incision in 8 patients, again with good success, and were more comfortable using a pediatric resectoscope to perform this incision in 8. We have not had a need to use a pediatric resectoscope and have achieved good control with a standard, adult resectoscope. There is no agreement on where to cut the bladder neck in women (for example 12, 5 and 7 o clock positions). Incising laterally at the 5 or 7 o clock position gives one the option to cut the opposite side if the procedure does not yield acceptable results, which has been my practice. However, one must be careful not to cut too deep to the vaginal wall. Another form of voiding dysfunction in the differential diagnosis would be failure of the external sphincter to relax during voiding. As shown by Yalla and Resnick, 2 in some patients the external sphincter can extend to the bladder neck, which makes it difficult to differentiate external sphincter contractions from bladder neck dysfunction on video urodynamics. In this series needle electromyography was used, and it is not likely that any such patients were included. Video urodynamics remain the gold standard for the diagnosis of functional bladder neck obstruction. The authors have described this entity and treatment options, and have introduced -blockers into the treatment regimen. I agree that randomized trials to evaluate -blockers in this patient group would be ideal. However, such trials might encounter difficulty in enrolling patients because of the diagnostic testing needed to make an accurate diagnosis and the relatively few numbers of women with this condition. Nonetheless, I would applaud any such randomized double-blind placebo controlled studies in the future. Victor W. Nitti Department of Urology New York University Medical Center New York, New York REFERENCES 1. Nitti, V. W., Tu, L. M. and Gitlin, J.: Diagnosing bladder outlet obstruction in women. J. Urol., 161: 1535, Yalla, S. V. and Resnick, N. M.: Initiation of voiding in humans: the nature and temporal relationship of the urethral sphincter responses. J. Urol., 157: 590, 1997.