Voiding dysfunction in women: How to manage it correctly

INTRODUCTION

Of women aged >40 years, 6% have voiding dysfunction (VD), but the definition for VD in women with respect to detrusor underactivity (DU) and bladder outlet obstruction (BOO) is not yet clear. In this review we address the current literature to define the diagnosis and treatment of VD more accurately.

METHODS

We used the PubMed database (1975-2012) and searched for original English-language studies using the keywords 'female voiding dysfunction', 'detrusor underactivity', 'acontractile detrusor' and 'bladder outlet obstruction and urinary retention in women'. We sought studies including the prevalence, aetiology, pathogenesis, diagnosis and treatment of female VD.

RESULTS

In all, 20 original studies were identified using the selected search criteria, and another 45 were extracted from the reference lists of the original papers. All studies were selected according to their relevance to the current topic and the most pertinent reports were incorporated into this review.

CONCLUSION

Female VD might be related to DU or/and BOO. Voiding and storage symptoms can coexist, making the diagnosis challenging, with the need for a targeted clinical investigation, and further evaluation by imaging and urodynamics. To date there is no universally accepted precise diagnostic criterion to diagnose and quantify DU and BOO in women. For therapy, a complete cure might not be possible for patients with VD, therefore relieving the symptoms and minimising the long-term complications associated with it should be the goal. Treatment options are numerous and must be applied primarily according to the underlying pathophysiology, but also considering disease-specific considerations and the abilities and needs of the individual patient. The treatment options range from behavioural therapy, intermittent (self-)catheterisation, and electrical neuromodulation and neurostimulation, and up to urinary diversion in rare cases.

The satisfaction of patients with refractory idiopathic overactive bladder with onabotulinumtoxinA and augmentation cystoplasty

Objective

To assess the satisfaction of patients with refractory idiopathic overactive bladder (OAB) with two treatment methods, onabotulinumtoxinA (oBTX) and augmentation ileocystoplasty (AC).

Patients and methods

This prospective study included patients with refractory idiopathic OAB for >6 months and a urodynamic diagnosis of OAB. Oral pharmacotherapy had failed in all patients. Patients with any suspected neurological disorder were excluded. Before the procedure, patients completed the Urogenital Distress Inventory (UDI-6) and modified Incontinence Impact Questionnaire (IIQ-7), a neurological evaluation, a urodynamic study and their postvoid residual urine volume was measured. Patients were assigned to receive oBTX or AC, depending on patient’s preference. Follow-up visits were at 6 weeks and 3 and 6 months after the procedure. The OAB Satisfaction questionnaire (OAB-SAT-q) was used to assess satisfaction after the procedure.

Results

In all, 31 patients with refractory OAB were included, 16 in the oBTX group and 15 in the AC group. There was no significant difference between the groups in mean age, baseline OAB symptoms and urodynamic values. There were significant improvements in urinary symptoms (UDI-6) and quality of life (IIQ-7) after both procedures (except in the domain enquiring about difficulty, which significantly worsened after AC). Of the 16 patients, 15/16 and seven of 15 were completely dry after AC and oBTX, respectively. The overall and individual scores of the OAB-SAT-q were significantly higher among patients treated with AC than with oBTX. The incidence of the de novo need to use clean intermittent catheterisation after oBTX and AC was two of 16 and four of 15, respectively.

Conclusions

Both procedures are effective in improving the symptoms of OAB and of quality of life, but patients were more satisfied with AC than oBTX therapy.

Transobturator vaginal tape (inside-out) for stress urinary incontinence after radical cystectomy and orthotopic reconstruction in women

Objectives

To evaluate the safety and clinical efficacy of the transobturator vaginal tape ‘inside-out’ (TVT-O) procedure for managing new-onset stress urinary incontinence (SUI) after radical cystectomy (RC) and orthotopic W-neobladder construction in women.

Patients and methods

Between January 2004 and June 2010, 57 women were treated with RC and orthotopic ileal neobladder reconstruction. Six of these patients (median age 44 years, range 39–62; grade 2 muscle-invasive squamous cell carcinoma in four and transitional cell carcinoma in two) developed de novo SUI that was moderate in four and severe in two. The median (range) duration of SUI was 11 (9–18) months. All six patients underwent TVT-O for control of their SUI.

Results

Four patients were completely dry day and night (three of them can initiate voiding and one cannot, and uses intermittent catheterization). One patient improved, as assessed by using fewer pads (from 5–7 pads to 1 pad/day and night). She can initiate voiding but has minimal leakage only on moderate exertion. One patient who had severe SUI showed no improvement. Patients were followed for a mean (range) of 18 (17–32) months, with no deterioration in the continence status.

Conclusion

These encouraging results confirm the safety and clinical efficacy of TVT-O for managing new-onset SUI after RC and ileal neobladder construction, although a larger survey and a longer follow-up are needed.