Current Urology Reports

, Volume 13, Issue 5, pp 356–362 | Cite as

Evaluation and Management of Outlet Obstruction in Women Without Anatomical Abnormalities on Physical Exam or Cystoscopy

Voiding Dysfunction and Lower Urinary Tract Symptoms (GH Badlani and HB Goldman, Section Editors)

Abstract

Bladder outlet obstruction (BOO) in women can be either anatomic or functional. Anatomic causes for BOO are often readily apparent by history and physical exam. On the other hand, causes for functional obstruction, including dysfunctional voiding, primary bladder neck obstruction, and detrusor-external sphincter dyssynergia, are more difficult to establish. Because the appropriate treatment for functional obstruction drastically varies according to etiology, making an accurate diagnosis is paramount. Videourodynamics, interpreted in the context of individual clinical symptoms, remains the diagnostic gold standard in women with functional obstruction.

Keywords

Dysfunctional voiding Primary bladder neck obstruction Detrusor-external sphincter dyssynergia Urodynamics Women Functional obstruction 

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Groutz A, Blaivas JG, Pies C, Sassone AM. Learned voiding dysfunction (non-neurogenic, neurogenic bladder) among adults. Neurourol Urodyn. 2001;20(3):259–68.PubMedCrossRefGoogle Scholar
  2. 2.
    Farrar DJ, Osborne JL, Stephenson TP, Whiteside CG, Weir J, Berry J, et al. A urodynamic view of bladder outflow obstruction in the female: factors influencing the results of treatment. Br J Urol. 1975;47(7):815–22.PubMedCrossRefGoogle Scholar
  3. 3.
    Rees DL, Whitfield HN, Islam AK, Doyle PT, Mayo ME, Wickham JE. Urodynamic findings in adult females with frequency and dysuria. Br J Urol. 1975;47(7):853–60.PubMedCrossRefGoogle Scholar
  4. 4.
    Massey J. Obstructed Voiding in the Female. Br J Urol 1988.Google Scholar
  5. 5.
    Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Am J Obstet Gynecol. 2002;187(1):116–26.PubMedCrossRefGoogle Scholar
  6. 6.
    Abrams P. The assessment of prostatic obstruction from urodynamic measurements and from residual urine. Br J Urol 1979.Google Scholar
  7. 7.
    Schäfer W. Principles and clinical application of advanced urodynamic analysis of voiding function. Urol Clin North Am. 1990;17(3):553–66.PubMedGoogle Scholar
  8. 8.
    Nitti V, Tu L. Diagnosing bladder outlet obstruction in women. J Urol 1999.Google Scholar
  9. 9.
    Patel R, Nitti V. Bladder outlet obstruction in women: prevalence, recognition and management. Curr Urol Rep 2001.Google Scholar
  10. 10.
    Lemack GE. Urodynamic assessment of bladder-outlet obstruction in women. Nat Clin Pract Urol. 2006;3(1):38–44.PubMedCrossRefGoogle Scholar
  11. 11.
    Dmochowski RR. Bladder outlet obstruction: etiology and evaluation. Rev Urol MedRev LLC. 2005;7 Suppl 6:S3.Google Scholar
  12. 12.
    Farrar D, Warwick R. Outflow obstruction in the female. The Urologic clinics of North America; 1979.Google Scholar
  13. 13.
    Dwyer PL, Desmedt E. Impaired bladder emptying in women. Aust N Z J Obstet Gynaecol. 1994;34(1):73–8.PubMedCrossRefGoogle Scholar
  14. 14.
    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(3):408–11.PubMedCrossRefGoogle Scholar
  15. 15.
    Lemack GE, Zimmern PE. Pressure flow analysis may aid in identifying women with outflow obstruction. J Urol. 2000;163(6):1823–8.PubMedCrossRefGoogle Scholar
  16. 16.
    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(4):675–9. discussion679–81.PubMedCrossRefGoogle Scholar
  17. 17.
    Blaivas JG, Groutz A. Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology. Neurourol Urodyn. 2000;19(5):553–64.PubMedCrossRefGoogle Scholar
  18. 18.
    Akikwala TV, Fleischman N, Nitti VW. Comparison of diagnostic criteria for female bladder outlet obstruction. J Urol. 2006;176(5):2093–7.PubMedCrossRefGoogle Scholar
  19. 19.
    •• Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010. p. 4–20. This comprehensive work standardizes terminology for clinicians and researchers working in the field of female pelvic floor dysfunction. Google Scholar
  20. 20.
    Jørgensen TM, Djurhuus JC, Schrøder HD. Idiopathic detrusor sphincter dyssynergia in neurologically normal patients with voiding abnormalities. Eur Urol. 1982;8(2):107–10.PubMedGoogle Scholar
  21. 21.
    Cameron AP, Gajewski JB. Bladder outlet obstruction in painful bladder syndrome/interstitial cystitis. Neurourol Urodyn. 2009;28(8):944–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Pannek J, Einig E-M, Einig W. Clinical management of bladder dysfunction caused by sexual abuse. Urol Int. 2009;82(4):420–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Wood SK, Baez MA, Bhatnagar S, Valentino RJ. Social stress-induced bladder dysfunction: potential role of corticotropin-releasing factor. Am J Physiol Regul Integr Comp Physiol. 2009;296(5):R1671–8.PubMedCrossRefGoogle Scholar
  24. 24.
    •• Minardi D, d'Anzeo G, Parri G, Polito M, Piergallina M, El Asmar Z, et al. The role of uroflowmetry biofeedback and biofeedback training of the pelvic floor muscles in the treatment of recurrent urinary tract infections in women with dysfunctional voiding: a randomized controlled prospective study. Urology. 2010;75(6):1299–304. This study establishes pelvic floor physiotherapy with biofeedback as the golden standard primary treatment for dysfunctional voiding. PubMedCrossRefGoogle Scholar
  25. 25.
    Fan Y-H, Lin ATL, Wu H-M, Hong C-J, Chen K-K. Psychological profile of female patients with dysfunctional voiding. Urology. 2008;71(4):625–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Castro-Diaz D, Taracena Lafuente JM. Detrusor-sphincter dyssynergia. Int J Clin Pract Suppl. 2006;151:17–21.PubMedCrossRefGoogle Scholar
  27. 27.
    Xu D, Qu C, Meng H, Ren J, Zhu Y, Min Z, et al. Dysfunctional voiding confirmed by transdermal perineal electromyography, and its effective treatment with baclofen in women with lower urinary tract symptoms: a randomized double-blind placebo-controlled crossover trial. BJU Int. 2007;100(3):588–92.PubMedCrossRefGoogle Scholar
  28. 28.
    Rogalski MJ, Kellogg-Spadt S, Hoffmann AR, Fariello JY, Whitmore KE. Retrospective chart review of vaginal diazepam suppository use in high-tone pelvic floor dysfunction. Int Urogynecol J. 2010;21(7):895–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Phelan MW, Franks M, Somogyi GT, Yokoyama T, Fraser MO, Lavelle JP, et al. Botulinum toxin urethral sphincter injection to restore bladder emptying in men and women with voiding dysfunction. J Urol. 2001;165(4):1107–10.PubMedCrossRefGoogle Scholar
  30. 30.
    Fowler CJ, Betts CD, Christmas TJ, Swash M, Fowler CG. Botulinum toxin in the treatment of chronic urinary retention in women. Br J Urol. 1992;70(4):387–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Lee K-S, Han DH, Lee Y-S, Choo M-S, Yoo TK, Park HJ, et al. Efficacy and safety of tamsulosin for the treatment of non-neurogenic voiding dysfunction in females: a 8-week prospective study. J Korean Med Sci. 2010;25(1):117.PubMedCrossRefGoogle Scholar
  32. 32.
    Roth TJ, Vandersteen DR, Hollatz P, Inman BA, Reinberg YE. Sacral neuromodulation for the dysfunctional elimination syndrome: a single center experience with 20 children. J Urol. 2008;180(1):306–11. discussion311.PubMedCrossRefGoogle Scholar
  33. 33.
    Diokno AC, Hollander JB, Bennett CJ. Bladder neck obstruction in women: a real entity. J Urol. 1984;132(2):294–8.PubMedGoogle Scholar
  34. 34.
    • Brucker BM, Fong EDM, Shah SR, Kelly C, Rosenblum N, Nitti VW. Urodynamic differences between dysfunctional voiding and primary bladder neck obstruction in women. Urology. 2012;1(80):55–60. This study highlights the importance of using fluoroscopy during urodynamics to accurately distinguish between DV and PBNO. CrossRefGoogle Scholar
  35. 35.
    Leadbetter G, Leadbetter W. Diagnosis and treatment of congenital bladder-neck obstruction in children. N Engl J Med. 1959;260(13):633–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Kuo H-C. Videourodynamic characteristics and lower urinary tract symptoms of female bladder outlet obstruction. Urology. 2005;66(5):1005–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Kessler TM, Studer UE, Burkhard FC. The effect of terazosin on functional bladder outlet obstruction in women: a pilot study. J Urol. 2006;176(4 Pt 1):1487–92.PubMedCrossRefGoogle Scholar
  38. 38.
    Athanasopoulos A, Gyftopoulos K, Giannitsas K, Perimenis P. Effect of alfuzosin on female primary bladder neck obstruction. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(2):217–22.PubMedCrossRefGoogle Scholar
  39. 39.
    Turner-Warwick R, Whiteside CG, Worth PH, Milroy EJ, Bates CP. A urodynamic view of the clinical problems associated with bladder neck dysfunction and its treatment by endoscopic incision and trans-trigonal posterior prostatectomy. Br J Urol. 1973;45(1):44–59.PubMedGoogle Scholar
  40. 40.
    Jonas U, Petri E, Hohenfellner R. Indication and value of bladder neck incision. Urol Int. 1979;34(4):260–5.PubMedCrossRefGoogle Scholar
  41. 41.
    Grønbaek K, Struckmann J, Frimodt-Moller C. The treatment of female bladder neck dysfunction. Scand J Urol Nephrol. 1992;26(2):113–8.PubMedGoogle Scholar
  42. 42.
    Kumar A, Mandhani A, Gogoi S. Management of Functional Bladder Neck Obstruction in Women: Use of α-Blockers and Pediatric Resectoscope for Bladder Neck Incision. J Urol 1999.Google Scholar
  43. 43.
    Peng C-H, Kuo H-C. Transurethral incision of bladder neck in treatment of bladder neck obstruction in women. Urology. 2005;65(2):275–8.PubMedCrossRefGoogle Scholar
  44. 44.
    Jin X-B, Qu H-W, Liu H, Li B, Wang J, Zhang Y-D. Modified transurethral incision for primary bladder neck obstruction in women: a method to improve voiding function without urinary incontinence. Urology. 2012;79(2):310–3.PubMedCrossRefGoogle Scholar
  45. 45.
    Ahmed HU, Shergill IS, Arya M, Shah PJR. Management of detrusor–external sphincter dyssynergia. Nat Clin Pract Urol. 2006;3(7):368–80.PubMedCrossRefGoogle Scholar
  46. 46.
    Kim YH, Kattan MW, Boone TB. Bladder leak point pressure: the measure for sphincterotomy success in spinal cord injured patients with external detrusor-sphincter dyssynergia. J Urol. 1998;159(2):493–6. discussion496–7.PubMedCrossRefGoogle Scholar
  47. 47.
    Abdul-Rahman A, Ismail S, Hamid R, Shah J. A 20-year follow-up of the mesh wallstent in the treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury. BJU Int. 2010;106(10):1510–3.PubMedCrossRefGoogle Scholar
  48. 48.
    Chen S-L, Bih L-I, Huang Y-H, Tsai S-J, Lin T-B, Kao Y-L. Effect of Single Botulinum Toxin a Injection to the External Urethral Sphincter for Treating Detrusor External Sphincter Dyssynergia in Spinal Cord Injury. Medical Journals Limited; 2008.Google Scholar
  49. 49.
    Schurch B, Schmid DM, Knapp PA. An update on the treatment of detrusor–sphincter dyssynergia with botulinum toxin type A. Eur J Neurol Wiley Online Libr. 1999;6:s83–9.Google Scholar
  50. 50.
    de Sèze M, Petit H, Gallien P, de Sèze M-P, Joseph P-A, Mazaux J-M, et al. Botulinum a toxin and detrusor sphincter dyssynergia: a double-blind lidocaine-controlled study in 13 patients with spinal cord disease. Eur Urol. 2002;42(1):56–62.PubMedCrossRefGoogle Scholar
  51. 51.
    Smith CP, Nishiguchi J, O’Leary M, Yoshimura N, Chancellor MB. Single-institution experience in 110 patients with botulinum toxin A injection into bladder or urethra. Urology. 2005;65(1):37–41.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Duane Hickling
    • 1
  • Margarita Aponte
    • 1
  • Victor Nitti
    • 1
  1. 1.Department of UrologyNew York University Langone Medical CenterNew YorkUSA

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