Voiding dysfunction in women: How to manage it correctly. Arab J Urol. 2013;11:319-330. [PMID: 26558099 PMCID: PMC4443013 DOI: 10.1016/j.aju.2013.07.005]

Nonneurogenic female bladder outlet obstruction: Conservative and medical management

INTRODUCTION

In nonneurogenic female bladder outlet obstruction (BOO), management goals include reduction of outlet resistance to increase urinary outflow and improve bladder voiding to prevent or reduce lower and upper urinary tract (LUT and UUT) function deterioration, by correcting the underlying etiology. As significant progress has been achieved in the conservative and pharmacological management of nonneurogenic female BOO, the purpose of this article is to review and summarize the current literature.

MATERIALS AND METHODS

For this narrative review, a PubMed® search was performed by cross-referencing the keywords "female bladder outlet obstruction," "female voiding dysfunction," "conservative management," "pharmacological management," and "treatment" with various terms related to the management of female BOO. Clinical practice guidelines and landmark reviews from the most renowned experts in the field were also used.

MANAGEMENT

This review discusses and summarizes the conservative and pharmacological management of nonneurogenic female BOO based on the most relevant data currently available in the literature.

CONCLUSION

The recent advances in the understanding of underlying mechanisms involved in female BOO allow for more individualized management. Conservative and pharmacological options show interesting outcomes, particularly in the context of a functional cause of BOO. Overall, the level of evidence is still low regarding the use of conservative and pharmacological measures and more long-term data are required.

The effect of pelvic floor muscle training in women with functional bladder outlet obstruction

INTRODUCTION AND HYPOTHESIS

Female voiding dysfunction is often due to bladder outlet obstruction (BOO). We investigated pelvic floor muscle training (PFMT) effectiveness in women with functional BOO.

METHODS

This is a prospective study recruiting 63 women functionally obstructed, over 18yo, maximum flow rate (Qmax) less than 12 ml/sec, naïve of voiding treatment. Exclusion criteria were anatomical BOO, neurological condition, pelvic intervention, psychiatric or anticholinergic medication, diabetes mellitus and affected upper urinary tract. At baseline, women underwent uroflow, post void residual (PVR) measurement, cystoscopy, cystogram and urodynamic study (UDS) with pelvic electromyography (EMG). Blaivas-Groutz nomogram has been used to define obstruction. After diagnosis, patients underwent six-month PFMT. Re-evaluation was offered four weeks after end of treatment. Data were analyzed with SPSSv22.0.

RESULTS

63 women were recruited and 48 finally included. At baseline, 20 reported 3 urinary tract infections (UTIs) during last year, and 12 had one episode of urine retention. Median Qmax was 7.5 ml/sec and median PVR 110 ml. 40 women were obstructed. 16 (40%) had mild, 16 (40%) moderate and 8 (20%) severe obstruction. All subjects had an overactive pelvic floor on EMG. Obstructed women were re-evaluated. Median Qmax was 8.5 ml/sec, close to baseline (p = 0.16). Median PVR was 65 ml, reduced to baseline (p = 0.02). 33 (82.5%) remained obstructed, 22 (66.67%) with mild, 8 (24.24%) moderate and 3 (9.09%) severe obstruction. 7 (17.5%) were non-obstructed. 4 patients reported one UTI episode with no cases of retention.

CONCLUSIONS

A 6 month PFMT reduced UTIs and PVR in women with functional BOO. Additionally, most patients had a de-escalation to milder obstruction.

Botulinum toxin A injection to the external urethral sphincter for voiding dysfunction in females: A tertiary center experience

AIM

The aim of this study is to examine the functional outcomes of ona-botulinum toxin A (BTX-A) injection into the external urethral sphincter (EUS) for female patients with nonneurogenic nonrelaxing sphincter as the underlying cause of voiding dysfunction (VD).

METHOD

A retrospective analysis was performed for all the patients with the urodynamic findings of higher than expected maximum urethral closure pressure (MUCP) who received their first injection during the study period. All patients were evaluated with preoperative videourodynamic study and urethral pressure profilometry and received 100 U of EUS BTX-A. Patients aged less than 18 years and those with neurogenic bladder were excluded. All patients were followed up with the free flow, postvoid residuals (PVR), and patient global impression of improvement (PGI-I) scale at 6 weeks and then at 3 monthly intervals.

RESULT

We identified 35 female patients with a mean age of 37.5 ± 15 years (range 18-72 years) with a mean follow-up of 20 months. More than 50% of patients had a history of prior surgical intervention and 28 (80%) patients were catheter dependent, a suprapubic catheterization, or clean intermittent self-catheterization. Mean MUCP was 97.1 ± 22 cm of water. After treatment with BTX-A, 21 (60%) patients were able to void per urethral (p = 0.02). The mean maximum flow rate (Qmax) improved from 8.8 to 11 mls/s and the mean PVR decreased from 200 to 149 mls (p < 0.05). On multivariate analysis, we identified high preoperative PVR, high preoperative actual MUCP, and previous surgical intervention (urethral dilatation, sacral neuromodulation, and pelvic surgery) as predictors of successful voiding restoration. The mean duration of response was 4.7 months, 46% of patients requested repeat injection, and 29% were established on maintenance injections. On the 5-point PGI-I score, 13 (37%), 12 (34%), and 10 (29%) patients reported good, some, and no improvement, respectively. Quality of life was also improved in 60% of patients. Two patients had transient stress urinary incontinence (for <6 weeks) and there were no significant long-lasting adverse events.

CONCLUSION

EUS BTX-A is a valid treatment option for VD considering therapeutic options are limited. The patient must be made aware of the need for repeat treatments.

A giant calculus within urethral diverticulum causing urinary retention in an uncommunicative woman

Introduction

There is no prior case report of calculus within a female urethral diverticulum causing urinary retention. We present such a case successfully treated by transurethral lithotripsy.

Case presentation

A 34‐year‐old bedridden and uncommunicative woman with spinocerebellar degeneration presented with fever for 5 days. She was admitted to the hospital for a urinary tract infection with a 3‐cm calculus in the lower urinary tract. At the time of admission, acute urinary retention occurred. A bladder catheter was placed, and antibiotics were administered; both improved the urinary tract infection. Subsequently, transurethral lithotripsy was performed and revealed that the giant calculus was incarcerated within the urethral diverticulum. The bladder catheter was removed postoperatively, and urinary retention did not recur. No calculus reformation or urinary tract infections were observed for 6 months after discharge.

Conclusion

A giant calculus within a urethral diverticulum may cause acute urinary retention in an uncommunicative patient.

European Association of Urology Guidelines on the Management of Female Non-neurogenic Lower Urinary Tract Symptoms. Part 2: Underactive Bladder, Bladder Outlet Obstruction, and Nocturia

CONTEXT

Female lower urinary tract symptoms (LUTS) are a common presentation in urological practice. Thus far, only a limited number of female LUTS conditions have been included in the European Association of Urology (EAU) guidelines compendium. The new non-neurogenic female LUTS guidelines expand the remit to include these symptoms and conditions.

OBJECTIVE

To summarise the management of underactive bladder (UAB), bladder outlet obstruction (BOO), and nocturia in females.

EVIDENCE ACQUISITION

The literature search was updated in September 2021 and evidence synthesis was conducted using modified GRADE approach as outlined for all EAU guidelines. A new systematic review on BOO was carried out by the panel for purposes of this guideline.

EVIDENCE SYNTHESIS

The important considerations for informing guideline recommendations are presented, along with a summary of all the guideline recommendations.

CONCLUSIONS

Non-neurogenic female LUTS are an important presentation of urological dysfunction. Initial evaluation, diagnosis, and management should be carried out in a structured and logical fashion on the basis of the best available evidence. This guideline serves to present this evidence to practising urologists and other health care providers in an easily accessible and digestible format.

PATIENT SUMMARY

This report summarises the main recommendations from the European Association of Urology guideline on symptoms and diseases of the female lower urinary tract (bladder and urethra) not associated with neurological disease. We cover recommendations related to the treatment of underactive bladder, obstruction of the bladder outlet, and nighttime urination.

Medium-term effects on voiding function after pelvic reconstructive surgery of advanced pelvic organ prolapse: Is postoperative uroflowmetry necessary?

OBJECTIVE

To evaluate the necessity of postoperative repetitive uroflowmetry and postvoid residual volume (PVR) in women with advanced anterior vaginal prolapse.

METHOD

Women with anterior vaginal prolapse stages III and IV who underwent surgery were included in this prospective cohort study. The surgical procedures included laparoscopic sacrocolpopexy (LSC), transvaginal mesh repair (TVM) and native tissue repair (NTR). Uroflowmetry, a PVR examination, the Urinary Distress Inventory-6 (UDI-6) and the Urinary Impact Questionnaire-7 (UIQ-7) were administered pre- and postoperatively. Moreover, pre- and postoperative uroflowmetry parameters were compared in women with/without an improvement in voiding difficulties according to the answer of questionnaires at one year after surgery. Paired sample t-tests, Wilcoxon signed-rank test, χ2 tests were used for analyses.

RESULTS

A total of 85 women were included in the study, and data were available for 47 of them at 1-year follow-up. Approximately half of women with advanced anterior vaginal prolapse had symptoms of voiding dysfunction, the rate of which decreased to approximately 10% postoperatively. The UDI-6 and UIQ-7 indicated a significant improvement postoperatively from baseline (both p<0.05). The PVR decreased significantly after surgery (p = 0.000). Uroflowmetry parameters remained stable within 1 year after surgery (all p＞0.05) both in the improved and unimproved groups (both p＞0.05).

CONCLUSION

Symptoms of voiding dysfunction are improved significantly after surgery. Postoperative uroflowmetry appears to be unnecessary one year after pelvic floor reconstructive surgery.

Predictors of voiding dysfunction following Uphold™ mesh repair for the treatment of pelvic organ prolapse

OBJECTIVE

To identify factors associated with voiding dysfunction after Uphold™ transvaginal mesh (TVM) repair in women with pelvic organ prolapse (POP).

STUDY DESIGN

We performed a retrospective analysis of 110 women with symptomatic pelvic organ prolapse (POP), anterior vaginal wall prolapse and/or apical prolapse (stage II to IV) who were scheduled for Uphold™ mesh surgery from September 2015 through December 2016. All subjects underwent urinalyses, UDI-6, IIQ-7, ICI-Q, POPDI-6, and pelvic examinations using the POP quantification (POP-Q) staging system before and after surgeries, with follow-up durations ranging from 24-36 months.

RESULTS

A total of 12 (10.9 %) of 110 women reported voiding dysfunction after Uphold™ mesh surgery. Using univariate analysis, there were no differences in body mass index and urodynamic parameters between normal voiding group and dysfunctional voiding group (P > 0.05). However, in patients aged above 71, POPDI-6 score≧13, preoperative concomitant urinary hesitancy, and incomplete emptying were found to be significant predictors of voiding dysfunction following Uphold™ mesh surgeries (P < 0.05).

CONCLUSION

In patients aged above 71, POPDI-6 score≧13, preoperative concomitant urinary hesitancy, and incomplete emptying were significant predictors of voiding dysfunction after Uphold™.

Female bladder neck dysfunction-A video-urodynamic diagnosis among women with voiding dysfunction

OBJECTIVE

To investigate bladder neck dysfunction (BND) in women with voiding dysfunction by video-urodynamic study (VUDS) and to examine the therapeutic results of different BND subtypes.

MATERIALS AND METHODS

We retrospectively reviewed consecutive women who had undergone VUDS for investigation of voiding dysfunction at our institution. The diagnosis of BND was made based on a nonfunneling bladder neck with or without high voiding detrusor pressure. Patients diagnosed as BND were retrieved, and the urodynamic parameters were compared with patients with dysfunctional voiding (DV) and other bladder outlet obstructions (BOO).

RESULTS

Among 810 women with bladder outlet dysfunction, BND was noted in 100 (12.3%), poor pelvic floor relaxation in 336 (41.5%), DV in 325 (40.1%), cystocele in 19 (2%), and urethral stricture in 30 (4%). Compared with the normal tracing group, BND patients had a significantly smaller volume of bladder filling sensation (included first sensation of filling, full sensation and cystometric bladder capaicity) and a greater BOO index (BOOI) (all P < .05). Detrusor overactivity was noted in 46 (46%) BND patients. These urodynamic parameters in BND were not significantly different from patients with DV or other BOO. High-pressure BND had a greater BOOI, but low-pressure BND had a lower voiding efficiency. Both alpha-blocker therapy and transurethral incision of the bladder neck improved uroflow parameters in BND patients.

CONCLUSIONS

BND includes 12.3% of women with bladder outlet dysfunction. High-pressure BND can cause anatomical BOO, whereas low-pressure BND is likely to affect micturition through inhibiting detrusor contractility. VUDS is the mainstay diagnostic tool to diagnose BND in women.

[Predictive factors of immediate post-operative acute urinary retention or voiding dysfunction following mid-urethral sling surgery: A literature review]

OBJECTIVE

Immediate postoperative urinary retention (UR) and voiding dysfunction (VD) are some factors limiting outpatient procedure for mid-urethral sling (MUS) surgery in women presenting with stress urinary incontinence. The objective of the current review was to report the main predictive factors associated with immediate postoperative UR/VD following MUS surgery in women.

METHODS

A systematic review was performed using Medline database, according to PRISMA methodology, using following keywords midurethral sling; tension-free vaginal tape; TVT; transobturator tape; TOT; predicting factor; voiding dysfunction; urinary retention; postvoid residual; postoperative residue of urine.

RESULTS

Thirteen studies were included. Main clinical predictive factors associated with immediate postoperative urinary retention (UR) and voiding dysfunction (VD) were: previous pelvic surgery (hysterectomy, incontinence or pelvic organ prolapse surgery) [OR: from 3.7 ((CI95%: 1.14-12.33); P=0.029)] to 8.93 [(CI95%:1.17-61.1); P=0.035)], previous UR [OR: 415 (CI95%: 20-8619); P<0.001], age over 65 y/o [OR: 3,72 (CI95%:1.40-9.9); P<0.01], and general anesthesia [OR: 4.5 (CI95%:1.1-18.9); P=0.02]. Urodynamic predictive factors were underactive bladder at cystometry [OR: from 2.52 ([CI95%: 1.03-6.13]; P=0.042) to 5.6 ([IC95%: 1.6-19.2]; P=0.02] and preoperative maximum flow rate (Qmax) (the prevalence of UR was ranging from 12 to 35% when Qmax was under 15ml/s, versus 0% when Qmax was over 30ml/s).

CONCLUSION

Predictive factors associated with immediate postoperative UR/VD following MUS surgery in women were age over 65 y/o, previous pelvic surgery or previous UR, underactive bladder and preoperative Qmax under 15ml/s.

Internal Urethrotomy in Treatment of Female with Anatomical Bladder Outlet Obstruction

Background:

Bladder outlet obstruction (BOO) is a relatively infrequent urologic condition in women, but can cause bothersome symptoms. In this article, transurethral incisions of the bladder neck (TUIBN) and urethra in the treatment of anatomical BOO were assessed.

Materials and Methods:

A total of 23 women who referred with chronic lower urinary tract symptoms, urinary retention, and difficulty in micturition were assessed. Diagnose was made on the basis of urethrocystoscopy, voiding cystourethrography, and urodynamic studies. All patients underwent transurethral incisions of bladder neck contracture or site of observed urethral stenosis at 3- and 9-o'clock positions. Clinical improvements and complications were assessed by follow-up examination and International Prostate Symptom Score (IPSS) and quality of life (QOL) scoring before and after intervention.

Results:

All patients were followed for at least 6 months after intervention. Follow-up data were available for 19 (90.5%), 13 (61.9%), and 7 (33.3%) of patients at 12, 24, and 48 months' follow-up, respectively. During the follow-up period, the mean IPSS and QOL significantly changed from 26.84 to 10.74 and 4.76 to 2.32, respectively (P < 0.001). Approximately 66.7% had satisfactory outcomes, 47.7% patients after first, and 19.1% after second TUI. About9.5% patients developed new onset of stress urinary incontinence, one of them had indications of surgical intervention, and thus, symptoms were relieved by mid-urethral sling.

Conclusion:

Transurethral incision of bladder neck and urethra seems to be effective in relieving urinary symptoms of anatomical BOO in women. Complications may rarely occur and can be fully managed.

Uncommon cause of voiding dysfunction in a female patient-vaginal abscess: A case report

BACKGROUND

Vaginal abscess is a treatable disease and should be considered in female patients with voiding difficulties and perineal tenderness. There are no reported cases of vaginal abscess causing voiding dysfunction in the absence of a previous surgery. Early diagnosis and drainage of vaginal abscesses may lead to excellent outcomes.

CASE SUMMARY

We presented a case of vaginal abscess that caused voiding dysfunction without surgery history. A 64-year-old woman had a past history of type 2 diabetes mellitus. She came to our clinic following urinary difficulty with perineal tenderness. Bladder ultrasonography revealed a pelvic cystic lesion with a mass effect on the bladder. The presence of a vaginal abscess was suspected following pelvic examination and transvaginal ultrasound. After transvaginal drainage of the vaginal abscess and a full course of antibiotic treatment, she recovered well without any urination symptoms.

CONCLUSION

Voiding dysfunction caused by vaginal abscess is rare but should be considered in female patients with perineal tenderness.