BPH UBC Department of Urologic Sciences Lecture Series Objectives Today 1 Anatomy of the lower urinary tract A Innervation of the bladder B Normal voiding 2 Classify Neurogenic ID: 912745
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Slide1
Voiding Dysfunction &BPH
UBC Department of Urologic
Sciences Lecture Series
Slide2Objectives 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
Slide3Disclaimer: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 study
Slide4Disclaimer:These concepts were all addressed in Year 1 FERGU block: Normal and Dysfunctional Voiding
Slide5MCC Objectiveshttp://mcc.ca/examinations/objectives-overview/For LMCC Part 1Objectives applicable to this lecture:Urinary Tract Obstruction
Slide6Male Anatomy1
Slide7Female Anatomy1
Slide8AnatomyBladder 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)
Slide9Conceptual Neuro-anatomyParasympathetic PEESympathetic STORE
Slide10AnatomyNervesSympathetics(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 Spincter
Slide11AnatomyNerve 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 tone
Slide12Conceptual Neuro-anatomyParasympathetic PEESympathetic STORE
Slide13Objectives 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 & LUTS
Slide14VoidingVoidingFillingEmptying
Slide15VoidingNormal Filling Requires:Accommodation of urine volume at low pressure (compliance)Closed bladder outletNo involuntary detrusor contractionsNormal sensation of bladder filling
Slide16How 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
seal
Slide17How 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)
Slide18How 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 relaxation
Slide19V
Slide20Objectives 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 & LUTS
Slide21Neurogenic BladderDefinition: dysfunction of the urinary bladder due to neurologic dysfunction or insult
Slide22Classifying Neurogenic BladderUpper Motor Neuron “spastic”Lower Motor Neuron “flaccid”
Slide23Neurogenic 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 Overactivity
Slide24Neurogenic UMNUpper Motor Neuron DiseasesBasal Ganglia disease (Parkinson’s disease) Detrusor overactivity Contractions are short, relaxation of ext. sphincter is slowed urgency, urge incontinence, slow flow
Slide25Neurogenic UMNUpper Motor Neuron DiseasesSuprasacral spinal cord damageAbove T6reflex micturition with detrusor-sphincter dyssynergiaBelow T6
reflex micturition with detrusor-sphincter synergia
Slide26Neurogenic 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 T6reflex micturition
with detrusor-sphincter dyssynergiaBelow T6 reflex micturition with detrusor-sphincter synergia
Slide27Neurogenic LMNLower Motor NeuronSacral Spinal cord damage Pelvic fracture, cauda equinaAcontractile bladder, poor bladder sensation
Peripheral Nerve Damage. Diabetes, pelvic surgery, XRT
Slide28Objectives 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 & LUTS
Slide29Voiding Dysfunction
Slide30Voiding DysfunctionEtiologyFailure to Store (AKA Incontinence)Detrusor overactivityOutlet incompetenceFailure to Empty (AKA Retaining)Detrusor
underactivityOutlet obstruction
Slide31Voiding 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
Slide32Urge IncontinenceEtiologyStone, UTI, Tumor, Overactive BladderInvestigationsHx, PE +/- urodynamics
Slide33Urge IncontinenceTreatmentTreat underlying causeTimed voidingBladder training – BiofeedbackPharmacologicAnticholinergic – OxybutininTCA’s – ImipramineSurgicalBladder pacemaker
Bladder denervation (rare)Bladder Augmentation – MitrofanoffUrinary Diversion
Slide34Stress 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.
Slide35Stress 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 sphincter
Slide36Stress IncontinenceRetropubic Bladder Neck Suspension (BURCH)
Slide37Stress IncontinenceUrethral Slings
Slide38Stress IncontinenceArtificial Sphincter
Slide39Overflow IncontinenceEtiologyObstruction TreatmentTreat underlying cause, eg BPHAcontractile BladderTreatmentTimed VoidingDouble voidingClean intermittent Catheterization Keep bladder volumes < 400ml and pt dry between catheterizations
Indwelling CatheterSuprapubic Catheter
Slide40Transient 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 function
Slide41Transient 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 contraction
Slide42Voiding Dysfunction CaseSo, you have this “friend” that has mentioned they occasionally have a case of wet undies…
Slide43Dx?
Slide44Dx?
Slide45VoidingEvaluationHistory 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.)
Slide46VoidingPhysicalmental 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 symptoms
Slide47VoidingSpecial Urology TestsUrodynamicsUroflowmetryMultichannel urodynamicsVideo-urodynamicsEndoscopy (Cystoscopy)Upper tract imaging (renal ultrasound)
Slide48VoidingIndications 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 corrected
Slide49Objectives 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 & LUTS
Slide50Lower Urinary Tract Symptoms (LUTS)“.. A constellation of obstructive and irritative voiding disturbances of the lower urinary tract”
Slide51LUTSLUTSStorage 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 common
Slide52DDx 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 mass
Slide53Evaluation of LUTSHx IPSS/AUA symptom scorePEGeneral & GU exam, DRE, Focused Neurourologic Exam UA/ UCx
Slide54Evaluation 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.
Slide55LUTS HistorySome specific questions to askHematuriaDysuriaIncontinenceAbdo/flank painPrevious transurethral surgeryCNS, neurologic diseases (parkinson’s, stroke)Meds (oral decongestants, antidepressants)DMPrevious
STD’s or perineal trauma
Slide56LUTSRisk 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 LUTS
Slide57IPSSIPSS
Slide58LUTSDREHealthySymmetricsoftSize – walnut/20gat 20 years of ageUnhealthyHardAssymetricalNoduleenlarged
Slide59LUTSSize of gland NOT = LUTS severity
Slide60Benign Prostatic HyperplasiaBPH is prevalent and relevantDon’t forget it.
Slide61BPH AnatomyProstate has 2 main types of tissueStroma Smooth muscleCollagenEpitheliumBPH occurs in transitional zoneProstate Cancer typically occurs in peripheral zones
Slide62LUTS
Slide63BPHPrevalenceIncreasing 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 symptoms
Slide64Complications of BPH
Urinary retention
(acute or chronic)
Renal failure
Recurrent UTIs Bladder stones Hematuria
Slide65Current practiceThe therapeutic cascade (step-up):lifestyle measures,phytotherapyalpha blockade5 ARIscombination med therapyanticholinergics
(occasionally)intermediate therapies (MIS)intervention under GA (TUR, etc)
Slide66Lifestyle Modification decrease fluids caffeine alcohol time diuretics decongestants
exercise weight loss sleep apnea diet
Slide67BPH 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 ejaculation
Slide68BPH PharmacotherapyAlpha BlockersSide EffectsDizzinessAsthenia (fatigue)Nasal congestionRetrograde ejaculationOrthostatic hypotension (uncommon)Syncope (rare)
Slide69BPH Pharmacotherapy5 alpha reductase inbhibitors…FinasterideDutasteride Lets look at physiology....
Slide70Regulation 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 death
Slide71Two 5a-reductase (5-AR) Isoenzymes Convert Testosterone to DHT
Testosterone
Type II 5AR
Type I 5AR
ProstateenlargementDHTBartsch G et al. Eur Urol. 2000;37:367380
Slide72Different Type I and Type II 5-AR Isoenzyme Inhibition by Dutasteride and FinasterideDutasteride
Finasteride
Prostatevolumereduced
Bartsch G et al.
Eur Urol. 2000;37:367380.DHTTestosteroneType II 5ARType I 5ARDutasteride
Slide73BPH 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 blockers
Slide74Revised Nov 2008Incidence of Acute Urinary Retention at Year 4 by Baseline Prostate Volume Tertile
= Reduction in risk over 4 years (Life Table Analysis)
Slide75Incidence of BPH-Related Surgery at Year 4 by Baseline PSA Tertile
= Reduction in risk over 4 years (Life Table Analysis)
Slide76BPH Pharmacology5 Alpha reductase inhibitorsSide EffectsErectile Dysfunction <5%Decreased libido <4%Decreased Volume Ejaculate < 3%Gynecomastia <1%
Slide77BPH 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 Combo
Slide78BPH 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 prostatectomy
Slide79BPH and SurgeryIndications for surgerySymptoms refractory to medical therapyRecurrent UTIUrinary RetentionRecurrent HematuriaRenal ImpairmentBladder Calculi
Slide80TURP – Gold StandardTURP – Transurethral Resection of prostateElectrocautery resection of of prostatic tissue EndoscopicPt stay is usually 1 night
Slide81TURP
Slide82Before and After TURPBEFOREAFTER
Slide83TURPComplicationsBleedingPerforationTUR SyndromeWith prolonged procedureAbsorption of hypotonic solution leads to:Hyponatremia, hypervolemia, hypertension, mental confusion, seizures, nausea, vomiting, visual disturbancesOccurs in < 2% of cases
Slide84Other Surgical OptionsGreen light laser
Slide85Other Surgical OptionsOpen ProstatectomyFor LARGE prostates
Slide86Objectives 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