Voiding Dysfunction - PowerPoint Presentation

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Voiding Dysfunction &BPH

UBC Department of Urologic

Sciences Lecture SeriesSlide2

Objectives Today1. Anatomy of the lower urinary tractA) Innervation of the bladderB) Normal voiding2. Classify Neurogenic Bladder3. Classify Urinary IncontinenceA) Rx for different types of incontinence4. BPH & LUTSSlide3

Disclaimer:This is a lot of information to cover and we are unlikely to cover it all todayThese slides are to be utilized for your reference to guide your self studySlide4

Disclaimer:These concepts were all addressed in Year 1 FERGU block: Normal and Dysfunctional VoidingSlide5

MCC Objectiveshttp://mcc.ca/examinations/objectives-overview/For LMCC Part 1Objectives applicable to this lecture:Urinary Tract ObstructionSlide6

Male Anatomy1Slide7

Female Anatomy1Slide8

AnatomyBladder InnervationDetrusor  (parasympathetic S2,3,4)Trigone  (sympathetic L1,2)UrethraMaleInternal/Involuntary Sphincter (Sympathetic L1,2)ProstaticExternal/Voluntary Sphincter (Pudental S2,3,4)

MembranousBulbarPenile (spongy, pendulous etc)Slide9

Conceptual Neuro-anatomyParasympathetic PEESympathetic STORESlide10

AnatomyNervesSympathetics(T11-L2) = StoreFrom aortic and superior

hypogastric plexis  hypogastric nerves 

pelvic plexus cause detrusor relaxation and bladder neck contractionParasympathetics(S2,3,4) = PeeFrom pelvic splanchnic nerves cause detrusor to contractSomatic (voluntary) control



Pudendal nerve(S2,3,4)External SpincterSlide11

AnatomyNerve SummaryParasympathetic S2,3,4+ Bladder contraction, relax sphinctersArise from sacral CordSympathetic L1,2+ Tight trigone, + internal sphincter tone, relax detrusorArise from lumbarSomatic S2,3,4+ External sphincter toneSlide12

Conceptual Neuro-anatomyParasympathetic PEESympathetic STORESlide13

Objectives Today1. Anatomy of the lower urinary tractA) Innervation of the bladderB) Normal voiding2. Classify Neurogenic Bladder3. Classify Urinary IncontinenceA) Rx for different types of incontinence

4. BPH & LUTSSlide14

VoidingVoidingFillingEmptyingSlide15

VoidingNormal Filling Requires:Accommodation of urine volume at low pressure (compliance)Closed bladder outletNo involuntary detrusor contractionsNormal sensation of bladder fillingSlide16

How does filling work?As bladder fills  sympathetic reflex initiated to keep you dry! Stimulation of alpha adrenergic receptors at bladder neck  increase resistance of bladder neck Activation of beta3 receptors in detrusor inhibiting contraction Direct inhibition of detrusor motor neurons in sacral spinal cord Gradual increase in urethral pressure as bladder fills due to pudendal nerve activation of external sphincterFormation of urethral mucousal

sealSlide17

How does emptying work?Emptying Requires:Coordinated detrusor contraction of adequate magnitudeLowering of resistance at the level of the urinary sphincters (bladder outlet)Absence of obstruction (either anatomical or functional)Slide18

How does emptying work?Emptying  Specifically:Increased intravesical pressure produces the sensation of distension  I want to void!!Coordination of detrusor contraction and external sphincter relaxation Brain (pontine micturition center)  inhibits the steady state spinal reflex of staying continent:Stimulates Parasympathetics 

contraction of detrusorInhibits sympathetics = internal sphincter relaxation Inhibits

pudendal = External Sphincter relaxationSlide19

VSlide20

Objectives Today1. Anatomy of the lower urinary tractA) Innervation of the bladderB) Normal voiding2. Classify Neurogenic Bladder3. Classify Urinary Incontinence

A) Rx for different types of incontinence4. BPH & LUTSSlide21

Neurogenic BladderDefinition: dysfunction of the urinary bladder due to neurologic dysfunction or insult Slide22

Classifying Neurogenic BladderUpper Motor Neuron “spastic”Lower Motor Neuron “flaccid”Slide23

Neurogenic UMNUpper Motor Neuron Cerebral Injury (stroke,tumour,brain injury)Normal function to inhibit reflexive bladder emptyingAllows socially acceptable timing of voidingDysfunction leads to loss of voluntary control of micturitionDetrusor OveractivitySlide24

Neurogenic UMNUpper Motor Neuron DiseasesBasal Ganglia disease (Parkinson’s disease) Detrusor overactivity Contractions are short, relaxation of ext. sphincter is slowed  urgency, urge incontinence, slow flowSlide25

Neurogenic UMNUpper Motor Neuron DiseasesSuprasacral spinal cord damageAbove T6reflex micturition with detrusor-sphincter dyssynergiaBelow T6 

reflex micturition with detrusor-sphincter synergiaSlide26

Neurogenic UMNUpper Motor Neuron DiseasesCerebral Injury (stroke,tumour,brain injury) detrusor overactivityBasal Ganglia disease (Parkinson’s disease) Detrusor overactivityContractions are short, relaxation of ext. sphincter is slowed  urgency, urge incontinence, slow flow

Suprasacral spinal cord damageAbove T6reflex micturition

with detrusor-sphincter dyssynergiaBelow T6  reflex micturition with detrusor-sphincter synergiaSlide27

Neurogenic LMNLower Motor NeuronSacral Spinal cord damage Pelvic fracture, cauda equinaAcontractile bladder, poor bladder sensation

Peripheral Nerve Damage. Diabetes, pelvic surgery, XRTSlide28

Objectives Today1. Anatomy of the lower urinary tractA) Innervation of the bladderB) Normal voiding2. Classify Neurogenic Bladder

3. Classify Urinary IncontinenceA) Rx for different types of incontinence4. BPH & LUTSSlide29

Voiding DysfunctionSlide30

Voiding DysfunctionEtiologyFailure to Store (AKA Incontinence)Detrusor overactivityOutlet incompetenceFailure to Empty (AKA Retaining)Detrusor

underactivityOutlet obstructionSlide31

Voiding DysfunctionFailure to StoreUrge Incontinence -involuntary loss of urine with a strong desire to void.Stress Incontinence -loss of urine with increased intra-abdominal pressure (cough, laugh, jump, rise to standing etc).Overflow Incontinence -loss of urine with bladder over-distension.Functional Incontinence -loss of urine associated with cognitive or physical impairment.

Mixed Incontinence -combinations of above Slide32

Urge IncontinenceEtiologyStone, UTI, Tumor, Overactive BladderInvestigationsHx, PE +/- urodynamicsSlide33

Urge IncontinenceTreatmentTreat underlying causeTimed voidingBladder training – BiofeedbackPharmacologicAnticholinergic – OxybutininTCA’s – ImipramineSurgicalBladder pacemaker

Bladder denervation (rare)Bladder Augmentation – MitrofanoffUrinary DiversionSlide34

Stress Urinary IncontinenceEtiologyUrinary retention + incr abdo pressureDetrusor overactivity + incr abdo pressureIntrinsic sphincter deficiencyUrethral hypermobilityOften related to weak pelvic floor musclesRisk Factors

Obesity, female, pregnancy, Vaginal deliveries, hysterectomy, prostatectomy, family Hx, caucasian, smoking, strenuous activity.Slide35

Stress IncontinenceTreatmentKegel exercisesBiofeedbackPharmacologicAlpha agonist (TCA, SSRI’s, pseudoephedrine)  incr sphincter tone and bladder outflow resistanceEstrogen cream/pillPeriurethral collagen injections

PessariesSurgeryBladder neck suspension (Burch, MMK)Urethral Slings (TVT, TOT)Artificial sphincterSlide36

Stress IncontinenceRetropubic Bladder Neck Suspension (BURCH)Slide37

Stress IncontinenceUrethral SlingsSlide38

Stress IncontinenceArtificial SphincterSlide39

Overflow IncontinenceEtiologyObstruction TreatmentTreat underlying cause, eg BPHAcontractile BladderTreatmentTimed VoidingDouble voidingClean intermittent Catheterization  Keep bladder volumes < 400ml and pt dry between catheterizations

Indwelling CatheterSuprapubic CatheterSlide40

Transient Urinary IncontinenceDIAPERSD Delirium – cognitive dysfunction can impair voidingI Infection – bladder irritation A Atrophic Vaginitis – post menopausal may cause, nocturia, freq, urgencyP Pharmaceuticals/ PolypharmacyE Excessive Urine production – diuretics, untreated DMR Restricted mobilityS Stool Impaction/Constipation impairs bladder function and pelvic floor muscle functionSlide41

Transient Urinary IncontinencePharmaceuticalsDiureticsAnticholinergics – impair bladder contractionSedatives- bzd’s – deliriumNarcotics – impair bladder contraction, constipate, deliriumAlpha agonist – increase sphincter tone – retention (nasal decongestants, imipramine)Alpha blocker – lead to stress incontinenceCCB’s impair bladder contractionSlide42

Voiding Dysfunction CaseSo, you have this “friend” that has mentioned they occasionally have a case of wet undies…Slide43

Dx?Slide44

Dx?Slide45

VoidingEvaluationHistory Urgency, frequency, dysuriaAssociation with valsalva maneuver (sneeze,cough,lifting etc.)Medications (diuretics,benzos,narcotics)Fluid intakeBack or head injury

Parathesias, fecal incontinenceDiabetesOther neurological disease (MS, Parkinson etc.)Slide46

VoidingPhysicalmental status, mobilityabdominal and pelvic examneurological examanal tone, peri-anal sensationBulbocavernosus

reflex (S2,3,4)InvestigationsUrinalysis, serum creatinine

Voiding DiaryPost Void Residual (PVR; by U/S or catheterization)Urine cytology- pts with irritative voiding symptomsSlide47

VoidingSpecial Urology TestsUrodynamicsUroflowmetryMultichannel urodynamicsVideo-urodynamicsEndoscopy (Cystoscopy)Upper tract imaging (renal ultrasound)Slide48

VoidingIndications for Referral:History or physical suggestive of neurologic diseaseHematuria, recurrent UTIs, bladder stones, renal insufficiency (post-renal) with incontinenceElevated PVR, overflow incontinenceIncontinence in pts with prior lower GU surgeryPersistence of incontinence once reversible causes are correctedSlide49

Objectives Today1. Anatomy of the lower urinary tractA) Innervation of the bladderB) Normal voiding2. Classify Neurogenic Bladder3. Classify Urinary Incontinence

A) Rx for different types of incontinence4. BPH & LUTSSlide50

Lower Urinary Tract Symptoms (LUTS)“.. A constellation of obstructive and irritative voiding disturbances of the lower urinary tract”Slide51

LUTSLUTSStorage symptoms/ irritativeFrequency, urgency, nocturiaVoiding symptoms/ obstructiveHesitancy, slow stream, “stuttering” stream, straining to void, sense of incomplete emptying, “doub;e” voiding, post void dribbleDysuria and incontinence are not usually seen in uncomplicated BPH.Microhematuria is commonSlide52

DDx of LUTS in Old MenProstate: BPH, prostate cancer, prostatitisBladder: cystitis, bladder tumour, bladder stoneUrethra: urethral stricture, meatal stenosis, phimosis

Neurologic: Parkinson’s disease, stroke, Alzheimer’s disease, spinal cord diseaseOther: Diabetes, sleep apnea, medication, diet, distal ureteral

stone, pelvic massSlide53

Evaluation of LUTSHx IPSS/AUA symptom scorePEGeneral & GU exam, DRE, Focused Neurourologic Exam UA/ UCxSlide54

Evaluation of LUTS+/- Serum Creatinine+/- PSA+/- Post void residual (PVR)Measures amount of urine after voidingLarge volume may suggest blockageMeasured by bladder scanner (U/S) or Catheter+/- Abdo UltrasoundIf hematuria, renal impairment, UTI’s, atypical symptoms

+/- Cystoscopy+/- UrodynamicsIf urinary retention, incontinence, atypical symptoms, neurological disease.Slide55

LUTS HistorySome specific questions to askHematuriaDysuriaIncontinenceAbdo/flank painPrevious transurethral surgeryCNS, neurologic diseases (parkinson’s, stroke)Meds (oral decongestants, antidepressants)DMPrevious

STD’s or perineal traumaSlide56

LUTSRisk FactorsIncreasing ageWeight gain and abdominal adiposity in adulthood may contribute to LUTSExcessive alcohol drinking (>75 g/day) was associated with LUTS and BPSmoking – Nicotine increases sympathetic nervous system activity exacerbating LUTSSlide57

IPSSIPSSSlide58

LUTSDREHealthySymmetricsoftSize – walnut/20gat 20 years of ageUnhealthyHardAssymetricalNoduleenlargedSlide59

LUTSSize of gland NOT = LUTS severitySlide60

Benign Prostatic HyperplasiaBPH is prevalent and relevantDon’t forget it.Slide61

BPH AnatomyProstate has 2 main types of tissueStroma Smooth muscleCollagenEpitheliumBPH occurs in transitional zoneProstate Cancer typically occurs in peripheral zonesSlide62

LUTSSlide63

BPHPrevalenceIncreasing prevalence with age, 80% of 80yo’sPathophysiologyGrowth of stromal component of prostateIncreased alpha 1A receptors leading to increased smooth muscle toneSize and degree of BOO (bladder outlet obstruction) do not fully correlate with degree of symptomsSlide64

Complications of BPH

Urinary retention

(acute or chronic)

Renal failure

Recurrent UTIs Bladder stones HematuriaSlide65

Current practiceThe therapeutic cascade (step-up):lifestyle measures,phytotherapyalpha blockade5 ARIscombination med therapyanticholinergics

(occasionally)intermediate therapies (MIS)intervention under GA (TUR, etc) Slide66

Lifestyle Modification decrease fluids caffeine alcohol time diuretics decongestants

exercise weight loss sleep apnea dietSlide67

BPH PharmacotherapyAlpha BlockersTamsulosin (Flomax): α1-subtype A selective; 0.4 mg daily; similar effectiveness but significantly fewer side effects compared to other α-blockers; retrograde ejaculation prevalentSilodosin (Rapaflo): α

1-subtype A selective; 8 mg daily.SE: retrograde ejaculation. Rapid onset actionTerazosin (Hytrin): α

1 selective; 2 mg – 10 mg daily; approximately 70% of men experience “satisfactory” improvement in symptoms; common side effects include dizziness, fatigue and rhinorrheaDoxazosin (Cardura): α1 selective; 4 mg – 8 mg daily; side effects similar to terazosin; effectiveness similar to terazosin

Alfuzosin (

Xatral): α1-subtype A selective; 10 mg daily; similar to flomax but less retrograde ejaculationSlide68

BPH PharmacotherapyAlpha BlockersSide EffectsDizzinessAsthenia (fatigue)Nasal congestionRetrograde ejaculationOrthostatic hypotension (uncommon)Syncope (rare)Slide69

BPH Pharmacotherapy5 alpha reductase inbhibitors…FinasterideDutasteride Lets look at physiology....Slide70

Regulation of Cell Growth in the Prostate in BPH

DHT-androgen receptor complex Growth factors Unbalanced DHT T 5AR (1 and 2) Serum DHT

Serum testosterone (T) Prostatecell IncreasedCell growthCell deathSlide71

Two 5a-reductase (5-AR) Isoenzymes Convert Testosterone to DHT

Testosterone

Type II 5AR

Type I 5AR

ProstateenlargementDHTBartsch G et al. Eur Urol. 2000;37:367380Slide72

Different Type I and Type II 5-AR Isoenzyme Inhibition by Dutasteride and FinasterideDutasteride

Finasteride

Prostatevolumereduced

Bartsch G et al.

Eur Urol. 2000;37:367380.DHTTestosteroneType II 5ARType I 5ARDutasterideSlide73

BPH Pharmacotherapy5 alpha reductase inhibitors:Reduce rate of Acute Urinary RetentionDecrease rate of surgery over 6 yearsWork best in larger prostatesDecrease size by 25%Decrease PSA by 50%Slower onset of action than alpha blockersSlide74

Revised Nov 2008Incidence of Acute Urinary Retention at Year 4 by Baseline Prostate Volume Tertile

= Reduction in risk over 4 years (Life Table Analysis)Slide75

Incidence of BPH-Related Surgery at Year 4 by Baseline PSA Tertile

= Reduction in risk over 4 years (Life Table Analysis)Slide76

BPH Pharmacology5 Alpha reductase inhibitorsSide EffectsErectile Dysfunction <5%Decreased libido <4%Decreased Volume Ejaculate < 3%Gynecomastia <1%Slide77

BPH PharmacotherapyCombination of Alpha Blockers and 5 Alpha reductase inhibitorsLong and short of it is:IF prostate small and PSA lowUse alpha blockerIF prostate large and PSA highUse ComboSlide78

BPH and SurgerySurgical Options“Minimally invasive therapy”Injections – eg. Botox™, alcoholPhotodynamic therapy (PTD)Microwave heat treatmentHigh Intensity Frequency Ultrasound (HIFU)Needle ablation / radio-wave treatmentElectrovaporization of prostateGreen light Laser therapy

Transurethral resection (TURP)Open prostatectomySlide79

BPH and SurgeryIndications for surgerySymptoms refractory to medical therapyRecurrent UTIUrinary RetentionRecurrent HematuriaRenal ImpairmentBladder CalculiSlide80

TURP – Gold StandardTURP – Transurethral Resection of prostateElectrocautery resection of of prostatic tissue EndoscopicPt stay is usually 1 nightSlide81

TURPSlide82

Before and After TURPBEFOREAFTERSlide83

TURPComplicationsBleedingPerforationTUR SyndromeWith prolonged procedureAbsorption of hypotonic solution leads to:Hyponatremia, hypervolemia, hypertension, mental confusion, seizures, nausea, vomiting, visual disturbancesOccurs in < 2% of casesSlide84

Other Surgical OptionsGreen light laserSlide85

Other Surgical OptionsOpen ProstatectomyFor LARGE prostatesSlide86

Objectives Today1. Anatomy of the lower urinary tractA) Innervation of the bladderB) Normal voiding2. Classify Neurogenic Bladder3. Classify Urinary IncontinenceA) Rx for different types of incontinence4. BPH & LUTS