Urethral Obstruction

Jerry G. Blaivas, MDClinical Professor of UrologyWeil Cornell Medical College

New York Presbyterian Medical Center

Adjunct Professor of UrologySUNY Downstate Medical Center

Urethral Obstruction

• Incidence: 2 - 29% of women with persistent LUTS

• Symptoms: nothing characteristic– storage 29%– voiding 8%– both 63%

B Blaivas & Groutz, , Neurourol & Urodynam 19:553, 2000; Nitti et al, J Urol, 1999

Diagnosis

• Suspect in:– all women with low Q– with grade 3 & 4 POP– sx onset after incontinence/ prolapse surgery

• Urodynamics (synchronous pdet / Q)

• Cystoscopy

Urethral obstruction

• High detrusor pressure(pdet > 20 cm H20)

• Low uroflow(Qmax < 12 ml/S)

2

Strss

High pressure

Low flow

Impaired Detrusor Contractility

• Weak & or poorly sustained detrusorcontraction (pdet < 20 cm H20)

• Low flow (Qmax < 12 ml/S)

JK

Low pressure

Low flow

Blaivas - Groutz Nomogram

0

20

40

60

80

100

120

140

160

0 10 20 30 40 50Free Qmax (ml/ sec)

pdet

.max

(cm

H2O)

Moderate obstruction (2)

Severe obstruction (3)

Mild obstruction (1)Unobstructed (0)

Blaivas & Groutz, Neurourol & Urodynam 19:553-564, 2000.

Diagnosis• ”…radiographic evidence of obstruction…

in the presence of a sustained detrusor contraction.”

• No specific UDS criteria

• Obstructed women had:– lower Qmax – higher Pdet@Qmax – higher PVR

• 23% of 331 women were obstructed

Nitti et al, J Urol, 1999

Caveats• A pressure flow diagnosis is usually

definitive, but

• An acontractile detrusor or impaired detrusor contractility does not rule out obstruction

• Persistent voiding dysfunction after incontinence surgery is usually due to obstruction

Etiology

Groutz et al, Neurourol Urodyn 19:213,2000; Nitti et al., 1999

Prior surgery 14 - 30%

Prolapse 29%

Stricture 15%1O bladder neck obstruction 10 - 16%

DESD 6%

Dysfunction voiding 6 - 33%

Urethral diverticulum 4%

Urethral Obstruction in women

• Anatomic

• Functional

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic• Idiopathic

• Atrophy

Functional Urethral Obstruction

• Primary vesical neck

• Neurogenic

• Acquired behavior

Rx Anatomic Urethral Obstruction

• Intermittent catheterization

• Surgery - depends on the cause:– correct prolapse– sling incision / urethrolysis– urethral diverticulectomy– urethroplasty

Rx Functional Urethral Obstruction

• Primary vesical neck• TUI / TUR of vesical neck• ? Alpha adrenergic antagonists

• Neurogenic• Intermittent catheterization +/-

• anticholinergics• Botox• enterocystoplasty

• Dysfunctional voiding•Bmod / biofeedback / neuromodulation

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic• Idiopathic

• Atrophy

MSCO

MSCO MSCO

High pressure

Low flow

Rx of Post-op Obstruction

• First 3 months – monitoring vs intervention• May experience improvement• Depends on procedure done

• After 3 months• Improvement unlikely• Definitive treatment

Mid Urethral Sling Loosening(1-2 weeks)

• Local anesthesia

• Open vaginal suture line

• Hook sling with a right-angle clamp

• Spread clamp or downward traction on

the tape will usually loosen it (1-2 cm)

• If the tape is fixed, it can be cut

Sling Incision

• Pull down on Foley and palpate sling

• Inverted U or midline incision

• Begin urethral dissection just proximal to sling

• Isolation of sling in the midline or lateral

• Incision of the sling

Nitti VW, Carlson KV, Blaivas JG, Dmochowski RR, Urology 59:47, 2002

DS

Sling Incision• Sling should spring

apart

• If not, dissect it from urethra

• +/- urethrolysis

TVT Intervention Results

N Type Success

Klutke, et al* 17 Midline Incision 100% normal emptying

Rardin, et al** 23 Midline Incision 100% normal emptying Loosening 30% complete resol. irritative sx 70% partial resol. irritative sx

* Recurrent SUI in 6%** Significant recurrent SUI 13%

26% recurrent SUI, but significantly better than prior to TVT

Sling Incision Results

N Type SuccessSUI

Klutke, et al Urology 58:697, 2001

Nitti, et al 19 Midline Incision 84% 17%

Amundsen, et al 32 Various 94% retention 9%

67% UUI

Goldman 14 Midline Incision 93% 21%

Urethrolysis

• Transvaginal• Anterior vaginal wall• Suprameatal

• Retropubic

Transvaginal Urethrolysis

• Inverted U incision

• Lateral dissection superficial to PCV

• Endopelvic fascia perforated & retropubic space entered

Transvaginal Urethrolysis• Sharp and blunt dissection • urethra freed from lateral

attachments & undersurface of the pubic bone

• Index finger placed between pubic bone and urethra

• +/- Martius flap interposition

Urethrolysis Results N Type Success SUI

Foster & McGuire 48 Transvaginal 65% 0

Nitti & Raz 42 Transvaginal 71% 0

Cross, et al 39 Transvaginal 72% 3%

Goldman, et al 32 Transvaginal 84% 19%

Petrou, et al 32 Suprameatal 67% 3%

Webster & Kreder 15 Retropubic 93% 13%

Petrou & Young12 Retropubic 83% 18%

Carr & Webster 54 Mixed 78% 14%

Retropubic Urethrolysis• Mobilization of urethra by sharp

dissection

• Restore complete mobility to anterior

vaginal wall

• Paravaginal repair

• Interposition of omentum between

urethra and pubic bone

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic

• Atrophy

Pdet @ Qmax = 36cm H2O

Qmax = 8 ml/S

symphysis

urethra

Pdet @ Qmax = 54 cm H2O

Qmax = 2 ml/S,

symphysis

Prolapsedbladder

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic

• Atrophy

FSFS

pdet@Qmax = 68 cm H20

Qmax = 5 ml/S

Tic

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic

• Atrophy

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic• Idiopathic

• Atrophy

pdet@Qmax = 25 cm H20

Qmax = 0.5 mL/S

Urethral diverticulum

Bladder diverticulum

Urethra

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic• Idiopathic

• Atrophy

JT

JT

pdet@Qmax = 75 cm H20

Qmax = 8 ml/SUrethral obstruction

stricture

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic• Idiopathic

• Atrophy

pdet@Qmax = 100 cm H20

Qmax = 0.5 mL/S

stricture

Surgical Rx of Stricture

• Urethral dilation

• Urethrotomy

• Urethroplasty• Ventral flap• Dorsal graft

Buccalgraft

Buccalgraft

Anatomic Urethral Obstruction• Compression

• Post surgical• Prolapse• Urethral Diverticulum• Tumor

• Urethral stricture• Post surgical• Traumatic• Idiopathic

• Atrophy

RSN

pdetmax = 90 cm H20

Qmax = 7 ml/S

RSN

urethra

diverticula

Functional Urethral Obstruction

• Primary vesical neck

• Neurogenic

• Acquired behavior

2

Strss

pdet@Qmax = 150 cm H20

Qmax = 1 ml/S

Rx Primary Vesical Neck Obstruction

• Alpha adrenergic blockade

• Bladder neck incision

• Bladder neck resection

Functional Urethral Obstruction

• Primary vesical neck

• Neurogenic

• Acquired behavior

PS

Involuntary detrusor contraction

Involuntary sphincter contraction

Obstruction due to sphincter contraction

CG

Involuntary detrusor contraction

Involuntary sphincter contraction

Vesical neck obstruction

Functional Urethral Obstruction

• Primary vesical neck

• Neurogenic

• Acquired behavior

Detrusor contractionSphincter contraction

Low, interrupted flow

Obstruction by sphincter

Impaired Detrusor Contractility

• Low flow

• Weak or poorly sustained detrusor contraction

• Pressure flow criteria: – Qmax < 12 ml/s– Pdet@Qmax < 20 cm H2O

Groutz et al, Neurourol Urodyn 19:213,2000

amb

pdetmax = 10 cm H20)

Qmax = 8 ml/S

Impaired Detrusor Contractility:Etiology

• Neurogenic– Thoracic, lumbar & sacral lesions– Diabetes mellitus

• Myogenic– Primary / idiopathc– Urethral obstruction– Bladder overdistension

• Urethral obstruction• Post-surgical

– Ischemia

Groutz et al, Neurourol Urodyn 19:213,2000

Impaired Detrusor Contractility:Treatment

• Observation• Double voiding• Timed voiding • Intermittent catheterization• ? Medications

– Cholinergic agonists– Alpha adrenergic antagonists

Conclusion• Urethral obstuction not uncommon• Prevalence: 2 - 29% of pts with LUTS• Symptoms – non-specific

–irritative 29%–obstructive 8%–both 63%

• Diagnosis based on p/Q studies• Rx based on underlying cause usually

effective for both voiding and OAB sx