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Figure 16.4. two women with an intermittent urinary stream. in the top panel, a neurologically normal woman with dysfunctional voiding and outlet obstruction due to fowler’s syndrome. Lower panel;voiding cystometrogram from a female patient with multiple
occur as a consequence of problems in the sacral part of the spinal cord causing tonic contraction.81 It is also seen when there is loss of communication between the brainstem and the lower urinary tract, which results in detrusor sphincter dyssynergia (DSD).82 DSD is common in high spinal cord injury and also occurs in advanced multiple sclerosis. It gives rise to a characteristically intermittent flow rate, and post-void residuals tend to be significant. Because of the high pressures generated during voiding, upper urinary tract function
sclerosis.the trace shows a wandering, poorly sustained detrusor contraction, resulting in an intermittent and very poor flow, with incomplete emptying. it would be extremely hard to ascertain whether outlet obstruction is also present in this patient.
can be impaired, leading to hydronephrosis and renal failure.83 When examined endoscopically, the bladder neck of these patients is often hypertrophied, and the bladder wall itself is trabeculated and diverticulated.
Conclusions
Both men and women are at risk of BOO, but the more homogenous nature of BOO in men has
216 Practical Urology: EssEntial PrinciPlEs and PracticE
allowed a standard approach to diagnosis,which |
13. |
Andersson KE. Detrusor contraction – focus on mus- |
||
is lacking in women.Anatomical constriction or |
|
carinic receptors. Scand J Urol Nephrol Suppl. 2004; |
||
distortion (or direct blockage from a foreign |
|
215:54-57 |
||
14. |
Drake MJ. The integrative physiology of the bladder. |
|||
body) result in BOO. In addition, excessive |
||||
|
Ann R Coll Surg Engl. 2007;89:580-585 |
|||
sphincter activity, as a result of neurological |
|
|||
15. |
Ho KM, McMurray G, Brading AF, Noble JG, Ny L, |
|||
disease of the CNS, or idiopathic overactivity of |
|
Andersson KE. Nitric oxide synthase in the heteroge- |
||
the sphincter muscles themselves, is an unusual |
|
neous population of intramural striated muscle fibres of |
||
but important patient group. Diagnosis cannot |
|
the human membranous urethral sphincter. J Urol. |
||
rely on symptoms alone, and an overall impres- |
|
1998;159:1091-1096 |
||
16. |
Ho KM, Ny L, McMurray G, Andersson KE, Brading AF, |
|||
sion, using symptoms, flow rate testing, cys- |
||||
|
Noble JG. Co-localization of carbon monoxide and nitric |
|||
tometrogram, and imaging all have a part to |
|
|||
|
oxide synthesizing enzymes in the human urethral |
|||
play. |
|
sphincter. J Urol. 1999;161:1968-1972 |
||
|
|
17. |
Abrams P, Cardozo L, Fall M, et al. The standardisation of |
|
|
|
|
terminology of lower urinary tract function: report from |
|
|
|
|
the Standardisation Sub-committee of the International |
|
References |
|
Continence Society. Neurourol Urodyn. 2002; 21:167-178 |
||
18. |
Abrams P, Cardozo L, Fall M, et al. The standardisation |
|||
|
|
|
of terminology of lower urinary tract function: report |
|
1. |
Yucel S, Baskin LS. An anatomical description of the |
|
from the Standardisation Sub-committee of the Inte- |
|
|
male and female urethral sphincter complex. J Urol. |
|
rnational Continence Society. Am J Obstet Gynecol. |
|
|
171:1890-1897 |
|
2002;187:116-126 |
|
2. |
Wallner C, Dabhoiwala NF, Deruiter MC, Lamers WH. |
19. |
de la Rosette JJ,Witjes WP, Schafer W, et al. Relationships |
|
|
The anatomical components of urinary continence. Eur |
|
between lower urinary tract symptoms and bladder out- |
|
|
Urol. 2009;55(4):932-943 |
|
let obstruction: results from the ICS-“BPH” study. |
|
3. |
Ashton-Miller JA, DeLancey JO. Functional anatomy of |
|
Neurourol Urodyn. 1998;17:99-108 |
|
|
the female pelvic floor. Ann NY Acad Sci. 2007;1101: 266- |
20. |
Pandita RK, Fujiwara M, Alm P, Andersson KE. |
|
|
296 |
|
Cystometric evaluation of bladder function in non- |
|
4. |
DeLancey JO. Structural support of the urethra as it |
|
anesthetized mice with and without bladder outlet |
|
|
relates to stress urinary incontinence: the hammock |
|
obstruction. J Urol. 2000;164:1385-1389 |
|
|
hypothesis. Am J Obstet Gynecol. 1994;170:1713-1720. |
21. |
Thomas AW, Cannon A, Bartlett E, Ellis-Jones J, Abrams |
|
|
discussion 20–3 |
|
P. The natural history of lower urinary tract dysfunction |
|
5. |
Brading AF. Spontaneous activity of lower urinary tract |
|
in men: minimum 10-year urodynamic followup of |
|
|
smooth muscles: correlation between ion channels and |
|
transurethral resection of prostate for bladder outlet |
|
|
tissue function. J Physiol. 2006;570:13-22 |
|
obstruction. J Urol. 2005;174:1887-1991 |
|
6. |
Brown M, Wickham JE. The urethral pressure profile. |
22. |
Haylen BT, Ashby D, Sutherst JR, Frazer MI, West CR. |
|
|
Br J Urol. 1969;41:211-217 |
|
Maximum and average urine flow rates in normal male |
|
7. |
Bolton JF, Whittlestone TH, Sibley GN. Comparisons of |
|
and female populations – the Liverpool nomograms. |
|
|
the responses of anterior and posterior human adult |
|
Br J Urol. 1989;64:30-38 |
|
|
male bladder neck smooth muscle to in vitro stimula- |
23. |
Siroky MB, Olsson CA, Krane RJ. The flow rate nom- |
|
|
tion. BJU Int. 2008;102:1737-1742 |
|
ogram: I. Development. J Urol. 1979;122:665-668 |
|
8. |
Sergeant GP, Thornbury KD, McHale NG, Hollywood |
24. |
Siroky MB, Olsson CA, Krane RJ. The flow rate nomo- |
|
|
MA. Interstitial cells of Cajal in the urethra. J Cell Mol |
|
gram: II. Clinical correlation. J Urol. 1980;123: 208-210 |
|
|
Med. 2006;10:280-291 |
25. |
Reynard JM, Yang Q, Donovan JL, et al. The ICS-“BPH” |
|
9. |
Ichiyanagi O, Sasagawa I, Suzuki Y, Ishigooka M, Nakada |
|
study: uroflowmetry, lower urinary tract symptoms and |
|
|
T. Relation between urethral elasticity and bladder out- |
|
bladder outlet obstruction. Br J Urol. 1998;82: 619-623 |
|
|
let obstruction and histologic composition of the pros- |
26. |
Pernkopf D, Plas E, Lang T, et al. Uroflow nomogram for |
|
|
tate in patients with benign prostatic hyperplasia. |
|
male adolescents. J Urol. 2005;174:1436-1439. discussion 9 |
|
|
Urology. 1999;53:1149-1153 |
27. |
Idzenga T, Pel JJ, van Mastrigt R. Accuracy of maximum |
|
10. |
Mitterberger M, Pinggera GM, Neuwirt H, et al. Three- |
|
flow rate for diagnosing bladder outlet obstruction can |
|
|
dimensional ultrasonography of the urinary bladder: |
|
be estimated from the ICS nomogram. Neurourol |
|
|
preliminary experience of assessment in patients with |
|
Urodyn. 2008;27:97-98 |
|
|
haematuria. BJU Int. 2007;99:111-116 |
28. |
Abrams PH, Griffiths DJ. The assessment of prostatic |
|
11. |
Sebe P, Fritsch H, Oswald J, et al. Fetal development of |
|
obstruction from urodynamic measurements and from |
|
|
the female external urinary sphincter complex: an ana- |
|
residual urine. Br J Urol. 1979;51:129-134 |
|
|
tomical and histological study. J Urol. 2005;173:1738- |
29. |
Abrams P, Blaivas JG, Stanton SL, Andersen JT. The stan- |
|
|
1742. discussion 42 |
|
dardisation of terminology of lower urinary tract func- |
|
12. |
Petros PE, Woodman PJ. The integral theory of conti- |
|
tion. The International Continence Society Committee |
|
|
nence. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19: |
|
on Standardisation of Terminology. Scand J Urol Nephrol |
|
|
35-40 |
|
Suppl. 1988;114:5-19 |
|
217
PathoPhysiology of lowEr Urinary tract obstrUction
30.Belal M, Abrams P. Noninvasive methods of diagnosing bladder outlet obstruction in men. Part 2: noninvasive urodynamics and combination of measures. J Urol. 2006;176:29-35
31.Belal M, Abrams P. Noninvasive methods of diagnosing bladder outlet obstruction in men. Part 1: nonurodynamic approach. J Urol. 2006;176:22-28
32.Harding CK, Robson W, Drinnan MJ, Griffiths CJ, Ramsden PD, Pickard RS.An automated penile compression release maneuver as a noninvasive test for diagnosis of bladder outlet obstruction. J Urol. 2004;172: 2312-2315
33.Griffiths CJ, Harding C, Blake C, et al. A nomogram to classify men with lower urinary tract symptoms using urine flow and noninvasive measurement of bladder pressure.J Urol.2005;174:1323-1326.discussion 6; author reply 6
34.Pel JJ, van Mastrigt R. A flow rate cut-off value as a criterion for the accurate non-invasive measurement of bladder pressure using a condom-type catheter. Urol Res. 2003;31:177-182
35.Oelke M, Hofner K, Jonas U, de la Rosette JJ, Ubbink DT, Wijkstra H. Diagnostic accuracy of noninvasive tests to evaluate bladder outlet obstruction in men: detrusor wall thickness, uroflowmetry, postvoid residual urine, and prostate volume. Eur Urol. 2007;52:827-834
36.Oelke M, Hofner K, Wiese B, Grunewald V, Jonas U. Increase in detrusor wall thickness indicates bladder outlet obstruction (BOO) in men. World J Urol. 2002;19: 443-452
37.Akikwala TV, Fleischman N, Nitti VW. Comparison of diagnostic criteria for female bladder outlet obstruction. J Urol. 2006;176:2093-2097
38.Blaivas JG, Groutz A. Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology. Neurourol Urodyn. 2000;19:553-564
39.Di Grazia E, Troyo Sanroman R, Aceves JG. Proposed urodynamic pressure-flow nomogram to diagnose female bladder outlet obstruction. Arch Ital Urol Androl. 2004;76:59-65
40.Gravina GL, Costa AM, Ronchi P, Galatioto GP, Luana G, Vicentini C. Bladder outlet obstruction index and maximal flow rate during urodynamic study as powerful predictors for the detection of urodynamic obstruction in women. Neurourol Urodyn. 2007;26:247-253
41.Kuo HC. Urodynamic parameters for the diagnosis of bladder outlet obstruction in women. Urol Int. 2004;72: 46-51
42.Chassagne S, Bernier PA, Haab F, Roehrborn CG, Reisch JS, Zimmern PE. Proposed cutoff values to define bladder outlet obstruction in women. Urology. 1998;51: 408-411
43.Lemack GE, Zimmern PE. Pressure flow analysis may aid in identifying women with outflow obstruction. J Urol. 2000;163:1823-1828
44.Defreitas GA, Zimmern PE, Lemack GE, Shariat SF. Refining diagnosis of anatomic female bladder outlet obstruction: comparison of pressure-flow study parameters in clinically obstructed women with those of normal controls. Urology. 2004;64:675-679. discussion 9–81
45.Nitti VW, Tu LM, Gitlin J. Diagnosing bladder outlet obstruction in women. J Urol. 1999;161:1535-1540
46.Cormier L, Ferchaud J, Galas JM, Guillemin F, Mangin P. Diagnosis of female bladder outlet obstruction and relevance of the parameter area under the curve of detrusor pressure during voiding: preliminary results. J Urol. 2002;167:2083-2087
47.Klijer R, Bar K, Bialek W. Bladder outlet obstruction in women: difficulties in the diagnosis. Urol Int. 2004;73: 6-10
48.Abrams P. LUTS, BPH, BPE, BPO: a plea for the logical use of correct terms. Rev Urol. 1999 Spring;1:65
49.Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol. 1984;132:474-479
50.Parsons JK, Bergstrom J, Silberstein J, Barrett-Connor E. Prevalence and characteristics of lower urinary tract symptoms in men aged > or = 80 years. Urology. 2008;72:318-321
51.McConnell JD, Roehrborn CG, Bautista OM, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med. 18, 2003;349: 2387-2398
52.Roehrborn CG. BPH progression: concept and key learning from MTOPS, ALTESS, COMBAT, and ALF-ONE. BJU Int. 2008;101(Suppl 3):17-21
53.Shirakawa T, Okada H, Acharya B, et al. Messenger RNA levels and enzyme activities of 5 alpha-reductase types 1 and 2 in human benign prostatic hyperplasia (BPH) tissue. Prostate. 1, 2004;58:33-40
54.Maruyama K, Fukutomi J, Chiba T, et al. Two district alpha(1)-adrenoceptor subtypes in the human prostate: assessment by radioligand binding assay using 3H-prazosin. Gen Pharmacol. 1996;27:1377-1381
55.Garg G, Singh D, Saraf S. Management of benign prostate hyperplasia: an overview of alpha-adrenergic antagonist. Biol Pharm Bull. 2006;29:1554-1558
56.Girman CJ, Jacobsen SJ, Guess HA, et al. Natural history of prostatism: relationship among symptoms, prostate volume and peak urinary flow rate. J Urol. 1995;153: 1510-1515
57.Lepor H, Williford WO, Barry MJ, Haakenson C, Jones K. The impact of medical therapy on bother due to symptoms, quality of life and global outcome, and factors predicting response. Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group. J Urol. 1998;160:1358-1367
58.Ilie CP, Chancellor MB. Perspective of botox for treatment of male lower urinary tract symptoms. Curr Opin Urol. 2009;19:20-25
59.Housami F, Abrams P. Persistent detrusor overactivity after transurethral resection of the prostate. Curr Urol Rep. 2008;9:284-290
60.Cranston D, Davies AH, Smith JC. Cobb’s collar – a forgotten entity. Br J Urol. 1990;66:294-296
61.Kajbafzadeh A. Congenital urethral anomalies in boys. Part I: posterior urethral valves. Urol J. Spring 2005;2: 59-78
62.Kajbafzadeh A. Congenital urethral anomalies in boys. Part II. Urol J. Summer 2005;2:125-131
218
Practical Urology: EssEntial PrinciPlEs and PracticE
63.Kim ED, Moty A, Wilson DD, Zeagler D. Treatment of a complete lower urinary tract obstruction secondary to an expandable foam sealant. Urology. 2002;60:164
64.Shetty BP, John SD, Swischuk LE,Angel CA. Bladder neck obstruction caused by a large simple ureterocele in a young male. Pediatr Radiol. 1995;25:460-461
65.Groutz A, Blaivas JG, Pies C, Sassone AM. Learned voiding dysfunction (non-neurogenic, neurogenic bladder) among adults. Neurourol Urodyn. 2001;20:259-268
66.Attaran M, Rome E, Gidwani GP. Unusual presentation of lichen sclerosuis in an adolescent. J Pediatr Adolesc Gynecol. 2000;13:99
67.Chou CP, Levenson RB, Elsayes KM, et al. Imaging of female urethral diverticulum: an update. Radiographics. 2008;28:1917-1930
68.Keegan KA, Nanigian DK, Stone AR. Female urethral stricture disease. Curr Urol Rep. 2008;9:419-423
69.Novi JM, Shaunik A, Mulvihill BH, Morgan MA. Acute urinary retention caused by a uterine leiomyoma: a case report. J Reprod Med. 2004;49:131-132
70.Advincula AP, Hernandez JC. Acute urinary retention caused by a large peritoneal inclusion cyst: a case report. J Reprod Med. 2006;51:202-204
71.Merlini E, Lelli Chiesa P. Obstructive ureterocele – an ongoing challenge. World J Urol. 2004;22:107-114
72.Romanzi LJ, Chaikin DC, Blaivas JG. The effect of genital prolapse on voiding. J Urol. February 1999;161:581-586
73.Mueller ER, Kenton K, Mahajan S, FitzGerald MP, Brubaker L. Urodynamic prolapse reduction alters urethral pressure but not filling or pressure flow parameters. J Urol. 2007;177:600-603
74.Ordorica R, Rodriguez AR, Coste-Delvecchio F, Hoffman M, Lockhart J. Disabling complications with slings for
managing female stress urinary incontinence. BJU Int. 2008;102:333-336
75.Hilton P. A clinical and urodynamic study comparing the Stamey bladder neck suspension and suburethral sling procedures in the treatment of genuine stress incontinence. Br J Obstet Gynaecol. 1989;96:213-220
76.Wang AC, Chen MC. Comparison of tension-free vaginal taping versus modified Burch colposuspension on urethral obstruction: a randomized controlled trial. Neurourol Urodyn. 2003;22:185-190
77.Wang AC. Burch colposuspension vs. Stamey bladder neck suspension. A comparison of complications with special emphasis on detrusor instability and voiding dysfunction. J Reprod Med. 1996;41:529-533
78.Goldman HB, Zimmern PE. The treatment of female bladder outlet obstruction. BJU Int. 2006;98:359-366
79.Bael A, Lax H, de Jong TP, et al. The relevance of urodynamic studies for urge syndrome and dysfunctional voiding: a multicenter controlled trial in children. J Urol. 2008;180:1486-1493. discussion 94–5
80.Swinn MJ, Fowler CJ. Isolated urinary retention in young women, or Fowler’s syndrome. Clin Auton Res. 2001;11:309-311
81.Sakakibara R, Hattori T, Uchiyama T, Yamanishi T, Ito H, Ito K. Neurogenic failures of the external urethral sphincter closure and relaxation; a videourodynamic study. Auton Neurosci. 14, 2001;86:208-215
82.Karsenty G, Reitz A, Wefer B, Boy S, Schurch B. Understanding detrusor sphincter dyssynergia – significance of chronology. Urology. 2005;66:763-768
83.Ahmed HU, Shergill IS,Arya M, Shah PJ. Management of detrusor-external sphincter dyssynergia. Nat Clin Pract Urol. July 2006;3:368-380