Voiding Dysfunction 2009 Block lecture, 5 th 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
Bladder pressure Micturition cycle Storage phase Emptying phase Storage phase Bladder filling Detrusor relaxes + Urethra contracts + Pelvic floor contracts First First sensation sensation to to void void Detrusor Detrusor relaxes relaxes + Urethra contraction Urethra contraction increases increases + Pelvic Pelvic floor contracts floor contracts Normal desire to void Detrusor contracts + Urethra relaxes + Pelvic floor relaxes Bladder filling Detrusor relaxes + Urethra contracts + Pelvic floor contracts MICTURITION
Normal voiding Bladder filling and urine storage require: 1. Accommodation of increasing volumes of urine at a low intravesical pressure and 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.
Normal voiding 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.
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 Symptom How to measure Causes Frequency Nocturia Urgency Incontinence Pain how many hours between voiding how many times the patient awakes from sleep to urinate Time per day, degree of leakage Time per day, pads per day Stress, total, overflow Suprapubic area functionally reduced bladder capacity, infection, tumor, stone, outlet obstruction, neurogenic bladder, or foreign body Infection, Insomnia, infection, drinking before bed. infection, BOO, or neurogenic bladder. the ultimate sign of storage failure, associated with urgency, frequency, or nocturia
Symptomatology: Obstructive symptoms Symptom hesitancy Straining to void Poor stream Dysuria Feeling of incomplete emptying Terminal dribbling Acute urinary retention How to measure Seconds, IPSS Discomfort Flowmetry (instrument) Discomfort,burning in urethra Residual urine (cath, ultrasound) Discomfort Cath.cc. Causes BPH, BOO, CBN, stricture urethra, prostate cancer UTI, urethritis BPH, BOO, CBN, stricture urethra, prostate cancer
Different type of incontinence
Differential diagnosis of voiding dysfunction Condition Malignant disease Infections Neurologic Medical Iatrogenic Anatomical Behavioral Pharmacological Other Adenocarcinoma of prostate,tcc of Bladder,Squamous cell CA of Penis Prostatitis, Urethritis, STD Spinal cord injury, cauda equina syndrome, Parkinsonism, Diabetic autonomic neuropathy, Multiple sclerosis, Alzheimer disease. Poorly controlled DM, Diabetes Insipidus, CHF, hypercalcemia, Obstructive sleep apnea. Post prostatectomy, Cystectomy, traumatic stricture, radiation cystitis. Ureteral and bladder stone Polydipsia, excessive alcohol or caffeine consumption. Diuretics, sympathomimetics, anticholinergic, decongestants. Overactive bladder dysfunction Cause of LUTS
Diseases usually cause voiding dysfunction pediatrics or congenital voiding dysfunction: posterior urethral valve phimosis? meatal stricture fistula ; ectopic ureteral opening, hypospadias,
Hypospadias
Cystitis disease usually cause voiding dysfunction 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
Type of cystitis when investigation needed. simple bacterial cystitis recurrent cystitis unresolved cystitis persistent cystitis honeymoon cystitis complicated cystitis anatomic abnormalities : post RT, contracted bladder, stricture urethra physiologic disorder: neurogenic, DM rare type bacteria; TB, granulamatous interstitial cystitis stone 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, wetting Hyporeflexic 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 Propantheline Oxybutynin Tolterodine tartrate Flavoxate (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 Resistance Ephedrine Estrogens
Drugs to Facilitate Emptying Increase Bladder Contractility Bethanechol chloride (Urecholine) Decrease Outlet Resistance Phenoxybenzamine (Dibenzyline) Prazosin (Minipress) Terazosin (Hytrin) Doxazosin (Cardura) Tamsulosin (Flomax) Alfuzosin (Xatral)
Bladder outlet obstruction BPH 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 prostatic enlargement (BPE), BOO, and LUTS to replace BPH.
Histologic BPH
Clinical BPH (with LUTS)
Not all LUTS is BPH LUTS 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 age range, yrs DRE negative DRE positive DRE suspected <60 60-70 >70
Objective measure of urine flow rate, Uroflowmetry : Qmax
Primary goals : Treatment goals for LUTS/BPH in clinical practice 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
Medical treatment Drug use for possible shrinkage of prostate 5 alpha reductase inhibitor (Finasteride) Drugs use for symptomatic relieve of LUTS alpha 1 blocker Doxazosin, Tamsulosin, Alfuzosin, Terazosin
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) Prostate volume (mean % change from baseline) 20 10 0 10 20 Baseline 1 2 3 4 Years McConnell JD et al. N Engl J Med 1998; 38: 557 63
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