W16: Urinary Retention in Women Workshop Chair: David Castro-Diaz, Spain 07 October 2015 08:30 - 11:30

Start End Topic Speakers 08:30 08:45 Urinary retention in women: concepts and pathophysiology David Castro-Diaz 08:45 08:50 Discussion All 08:50 09:05 Evaluation Tufan Tarcan 09:05 09:10 Discussion All 09:10 09:30 Conservative management Cristina Naranjo-Ortiz 09:30 09:35 Discussion All 09:35 09:55 Medical and surgical management Christopher Chapple 09:55 10:00 Discussion All 10:00 10:30 Break None 10:30 11:20 Typical clinical cases discussion All 11:20 11:30 Take home messages David Castro-Diaz

Aims of course/workshop Urinary retention in women is rare and diverse. Diagnostic criteria are not agreed and epidemiology is not well known. Forms of urinary retention in women include: complete retention, incomplete or insufficient emptying and elevated post-void residual. It may be acute or chronic, symptomatic or asymptomatic. Etiology is multifactorial including anatomic or functional bladder outlet obstruction and bladder dysfunction related to neurological diseases, diabetes mellitus, aging, pharmacotherapy, pain and infective/inflammatory disease and idiopathic or unknown aetiology. This workshop will analyse and discuss physiopathology, evaluation and management of urinary retention in women from an integral, practical and evidence based approach.

Learning Objectives 1. Identify urinary retention in women, its etiology and risk factors.

2. Carry out proper diagnosis of urinary retention in women as well as its relationship with risk and influent factors.

3. Properly manage female acute and chronic acute and chronic urinary retention with the different approaches including conservative, medical and surgical therapies.

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Acute urinary retention

• Men – BOO is common, diagnostic criteria are agreed, epidemiology Urinary retention in women: concepts and pathophysiology of acute retention is known D. Castro-Diaz • Women Prof. of Urology. University of La Laguna – BOO is rare and diverse, diagnostic criteria not agreed, Hospital Universitario de Canarias epidemiology not well known Spain – Varied voiding dynamics – Treatment outcome uncertain

Female Urinary Retention and Bladder Emptying Disorders Bladder dysfunction -Detrusor underactivity Neuropathic Complete retention • Lower motor neurons • Decentralizations Incomplete or insufficient emptying Myogenic Elevated postvoid residual (PVR) (Varied signficance) • Chronic obstruction or overdistention - • Diabetes mellitus Pharmacologic Post-surgical -Incontinence surgery • Anticholinergics -Pelvic surgery • α-agonists • Narcotics -Other Aging

-Acontractile bladder Symptomatic or asymptomatic • Failure of sphincteric relaxation Acute or chronic • Fowler’s syndrome • Learned • Pain

Bladder outlet dysfunction -Anatomic Urethral stricture in women • Iatrogenic Stricture Anti-incontinence surgery • Pelvic organ prolapse 3-8 % of women who present to urologist with voiding complaints • Extrinsic compression have BOO (Carr1996) • Gynaecologic tumours • Meatal stenosis The incidence of urethral stricture in women with BOO varies from • Caruncle 4% to 13% (Nitti 1999, Groutz 2000, Kuo 2005) • Skene’s gland abscess • Urethral diverticulum • Urethral carcinoma Female urethral stricture is typucally iatrogenic • Ectopic ureterocele • Retroverted impacted uterus (first trimester) -Functional • Primary bladder neck obstruction • Dysfunctional voiding • Detrusor external sphincter dyssynergia

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Two thick muscular layers: Longitudinal inner and circular outer Etiology of urethral stricture in women Both extensions of detrusor muscle Ending in the distal fourth of the urethra into a Rare entity thick collagenous ring (Lyon´s ring) Controversial etiology Likely that most cases are iatrogenic or traumatic in nature

Prolonged catheterization Pelvic radiation Childbirht Pelvic fracture Relevant to surgical planning Surgery for diverticulum, fistula or incontinence -Erectile tissue of the clitoris Urethral dilatation (periurethral fibrosis) and neurovascular bundles -Location of urogenital sphincter Small series & case reports Tuberculosis, vulvar dystrophy, lichen sclerosis, primary carcinoma, fibroepithelial Polyps, urethral leiomyoma, bladder drained pancreatic transplants, post TURBT Resection of sacrococcygeal teratoma & after female-to-male transsexual reconstruction

Urethral stricture in women Diagnosis Urodynamics and BOO in women Symptoms Frequency & urgency, dysuria, hesitancy, dribbling, incontinence and recurrent -Q max<12 ml/sec UTI (Migliari 2006) 2 or more of -Pdet@Qmax >50 cm H2O 2 Urinary retention (Merimsky 1985) -Urethral resistance (Ped@Qmax/Qmax ) > 0.2 Pdet = Pves-Pabd + Pabd Renal failure, hydronephrosis & pyelonephritis (Romero 1995) “Significant “ postvoid residual volume Massey & Abrams 1988 Stricture should be suspected if there is difficulty instrumenting the patient Pdet Qmax <15ml/sec + Pdet@Qmax >20 cm H2O Pves Physical examination Sensitivity = 74.3% Specificity = 91.1% for detecting BOO Pura EMG Urethral calibration Chassagne 1998 Qura Meatal stricture Q max =12 ml/sec (2-34) & median Pedt@Qmax =37 (10-116)

Voiding cystourethrogram (VCUG) Blaivas & Groutz nomogram for BOO 4 categories from no obstruction to severe obstruction Urethroscopy Poor correlation with symptom score index Nitti 1999 !Pressure-flow studies alone may fail to diagnose Urodynamics female BOO!

Female Urethral Dilatation for LUTS Background on Pelvic Floor Dysfunction (or Dysfunctional Voiding) Lyon & Smith 1963 : LUTS in girls were due to distal urethral stenosis • Intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the peri-urethral striated muscle during voiding, in neurologically normal individuals1 Empiric treatment of women and young girls with dysfunctional voiding &recurrent UTI • Broad range of symptoms and signs for several diagnoses affecting Today: Pelvic Floor Dysfunction sexual function, bowel function, urinary continence, and voiding Levator muscles as a potential source impairing urinary flow rate2. However 21% of urologists trained more than 12 years ago consider it very succesful (Lemack 1999) • Sphincter Vs levator muscles prognostic implications3 • Learned VD, Himman´s syndrome, non-neurogenic neurogenic bladder4 Avoid urethral dilatation

1.-Allen 1977 2.-Haylen 2009 ICS/IUGA 3.-Deindl 1998 4.-Himman 1986

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Background on Pelvic Floor Dysfunction Background of Primary Bladder Neck Obstruction (or Dysfunctional Voiding) • True Incidence not known 4.2% and 46.4% (Sinha 2011) • 2% of Urodynamic investigations (Groutz 2001) First described by Marion in 1933 • Sometimes with DOA, low compliance or V-U reflux (Jorgersen 1982) Turner-Warwick advocated Urodynamics and VCUG Diokno described the entity in 1984 Exact mechanism not fully understood Precise cause remains obscure In children is considered a habitual disorder learning to contract pelvic floor or external sphincter during micturition (Sinha 2011) Failure of dissolution of mesenchymal tissue at BN -Toilet training process Inclusion of abnormal connective tissue -Response to urgency Smooth muscle hypertrophy & inflammatory changes (Leadbetter 1959) -Associated to pelvic discomfort (constipation, abuse) Neurologic aetiology (Awad 1976) Occult neurogenic disorder It is possible that some women with DV were once children with DV

ICS Definition of detrusor underactivity Detrusor Function

• Is defined as a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span • DU is a urodynamic diagnosis based on a pressure– flow study and characterized by a low pressure, poorly sustained, or wavelike detrusor contraction with an Normal Underactive Acontrictile associated poor flow rate Detrusor detrusor Detrusor

• What about patients voiding completely with Valsalva?

DETRUSOR UNDERACTIVITY PATHOPHYSIOLOGY

Peripheral nerves CNS

Bladder wall

Nature Reviews Urology 7, 572-582 (October 2010) | doi:10.1038/nrurol.2010.147 EUROPEAN UROLOGY 6 5 ( 2 0 1 4 ) 3 9 9 – 4 0 1

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NEUROGENIC DETRUSOR Voiding without detrusor contraction UNDERACTIVITY START Uroflow Summery Value MCC Maximum flow 18.0 ml/s Average flow 7.5 ml/s Voiding flow 1:14.3 mm:ss.S This is a urodynamic dg Flow time 49.5 mm:ss.S Time to max. flow 43.5 mm:ss.S Voiding volume 372 ml Flow at 2 sec. 0.7 ml/s Acceleration 0.4 ml/s/s • Pressure at peak flow 7.5 cm H20 diabetes mellitus Flow at peak pressure 0.0 ml/s Peak pressure 12.4 cm H20 Mean pressure 2.9 cm H20 • Opening pressure 2.2 cm H20 Parkinson disease Closing pressure -6.5 cm H20 BOOI -28.0 BCI 97.0 BE n/a • multiple sclerosis (cereberal lesion) VOID 18/370/- no detrusor PVR n/a • injury to the spinal cord and cauda equina (eg, contraction herniated disc, pelvic fractures), • infectious neurologic problems (eg, AIDS, herpes zoster infection), • iatrogenic factors (e.g. pelvic surgery, radical prostatectomy)

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There is no strong consensus on the evaluation of FUR since the pathophysiology is poorly understood Female Urinary — On average women with FUR are seen by three hospital consultants before a diagnosis is made Retention (FUR): — Kavia, RBC et al, BJU INT, 2006 — Besides the transient causes, the etiology is related either to detrusor underactivity or increased outlet Evaluation resistance (sphincteric or anatomic) or to both of them Tufan Tarcan, MD, PhD — The influence of psychogenic factors, surgical Professor of Urology interventions and co-morbidities as possible Marmara University School of Medicine triggers remain to be clarified. Istanbul, Turkey

W16, ICS, October 7, 2015, Montreal

Goals of evaluation (1) Goals of evaluation (2) — To ensure bladder emptying until evaluation is — To assess the upper urinary tract (UUT) and take completed and management of retention is the necessary measures to prevent any further succeeded damage during evaluation process — Foley catheterization is usually the choice for acute — Bladder emptying with CIC is the mainstay of UUT retention protection — CIC should be preferred for periods longer than one — Ultrasound: basic imaging modality to assess the week UUT — Long-term indwelling catheterization is advised only — Renal function tests are needed in long term retention for frail pts when CIC cannot be performed

Transient causes of FUR: Invasive tools such as invasive UDS or cystoscopy Goals of evaluation (3) should be delayed if transient causes are present — To find out the etiology in order to treat FUR — Immobility (especially postoperative) — Transient causes — Constipation or fecal impaction — Persistent FUR — Medications — Will need more invasive neuro-urological evaluation such as UDS, cystoscopy and sphincter EMG — Urinary tract infections — Evaluation goes together with treatment since treatment — Delirium also starts with CIC — Endocrine abnormalities — FUR will resolve in a group of patients just with CIC after transient factors are eliminated — Psychological problems — Clot retention

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In fact, half of the women So, transient factors should be presenting with retention will carefully assessed and more void normally after transient invasive evaluation should be factors are eliminated spared for persistent cases.

Persistent Female Urinary Retention modified from: Padmanabhan and Rosenblum: Persistent Female Urinary Retention Idiopathic urinary retention in the female. In: Female Urology, pp 187-193, 2008 modified from: Padmanabhan and Rosenblum: Idiopathic urinary retention in the female. In: Female Urology, pp 187-193, 2008

Neurogenic Causes

Neurogenic Causes Increased Decreased bladder outlet contractility resistance

Non-neurogenic Causes

LMNL: -Cauda equina injury (e.g., distal spinal cord,intervertebral disk protrusion, myelodysplasia,primary and metastatic neoplasms, vascularmalformations) DSD: -Pelvic plexus injury -Suprasacral spinal cord injury -Peripheral neuropathy (e.g., diabetes mellitus,pernicious anemia, alcoholic neuropathy, Idiopathic Causes -Myelitis tabesdorsalis, herpes zoster, Guilland-Barrésyndrome, Shy-Drager syndrome) -Multiple sclerosis -Multiple sclerosis -Parkinson’s disease

Persistent Female Urinary Retention modified from: Padmanabhan and Rosenblum: Idiopathic urinary retention in the female. In: Female Urology, pp 187-193, 2008 Persistent Female Urinary Retention modified from: Padmanabhan and Rosenblum: Idiopathic urinary retention in the female. In: Female Urology, pp 187-193, 2008

Non-neurogenic Causes

Increased outlet resistance Decreased bladder contractility Idiopathic Causes

Anatomic causes: Functional causes -Hypotonia or atony -Primary bladder neck obstruction Chronic obstruction -Inflammatory processes (e.g., bladder neck fibrosis, urethral -Dysfunctional voiding stricture, meatal stenosis, urethral caruncle, Skene’s gland cyst -External sphincter Radiation cystitis spasticity or abscess, urethral diverticulum) Tuberculosis -Pelvic prolapse -Detrusor hyperactivity with impaired -Neoplasm (e.g., urethral carcinoma) contractility -Gynecologic, extrinsic compression (e.g., retroverted uterus, -Psychogenic retention vaginal carcinoma, cervical carcinoma, ovarian mass) -Infrequent voider’s syndrome -Iatrogenic obstruction (e.g., anti-incontinence procedures, multiple urethral dilations, urethral excision or reconstruction) -Miscellaneous causes (e.g., urethral valves, ectopic ureterocele, Fowler’s bladder calculi, atrophic vaginitis, reconstruction) syndrome

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Basic steps of evaluation The type of onset and age: There is a specific event that triggers FUR in (1) about half of the pts — Detailed history — Symptoms — Abdominal discomfort, — Emptying phase symptoms, — Recurrent urinary tract infections, — Incontinence

— Onset: acute or chronic — In chronic cases, some pts may not be aware of retention — High level of anxiety is seen in acute cases

Basic steps of evaluation Basic steps of evaluation (2) (3) — Detailed history — Physical examination — Childhood voiding history — Abdominal and sacral examination — Previous surgery — Pelvic examination — Anti-incontinence or other pelvic surgeries — Urethra, prolapse — Co-morbidities — Hormonal status, DM — Focused neurological examination — Medications that cause retention — SSRI, alpha agonists, anticholinergics, Calcium channel — Renal function tests and urine analysis blockers, Opioid analgesics, Psychotropic drugs — Constipation — Gynecological history — PCO, endometriosis

Urodynamic studies Problems with PFS — Uroflowmetry and PVR measurement — Women empty their bladders by relaxing the pelvic — In pts who are not in complete retention floor, — Cystometry and PFS with anal sphincter EMG — sometimes with the additional help from the — Detrusor underactivity is the most common finding abdominal muscles — PFS are not always helpful — without a strong detrusor contraction compared to — Urethral Pressure Profile men. — Fowler’s syndrome is associated with high urethral closing pressure in UPP and sphincter volume on US — Small changes in Pdet may define BOO — Video-urodynamics: should preferred when available — Difficult to develop reliable diagnostic nomograms — Many women cannot void in PFS — Since no test can accurately differentiate neurologic from non-neurologic female urinary retention, careful neurourologic evaluation will help guide — Obstructive effect of the cath. to more appropriate management. (ICI 2013)

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Suggested criteria for female Suggested criteria for female BOO (1) BOO (2)

— Qmax of 15 ml/s or less combined with pdetQmax of — Video UDS: radiographic evidence of obstruction 15 cm H2O or more between the bladder neck and distal urethra in the — Had a sensitivity of 80 % and a specificity of 83.1 % for presence of a sustained detrusor contraction of any BOO. magnitude during voiding… — Chassagne et al, 1998 — no strict pressure flow criteria — Nitti et al, 1999 — The same group revised their cutoff values — Using women with SUI as controls — Nomogram based on noninvasive Qmax and — Lemack, G. E. 2000 pdetmax — Asymptomatic women as controls. — Blaivas & Groutz, 2000 — Defreitas, G. A 2004 — Highest sensitivity and specificity were at Qmax 12 ml/s or less and pdetQmax 25 cm H2O or greater.

Suggested criteria for female BOO (3) Neurological evaluation — Comparison of 5 contemporary urodynamic — Starts with the focused neurological examination by definitions for female BOO on women who underwent the urologist videoUD — Neurology consultation is needed in persistent — Video-UD criteria and 1998 cutoff point criteria had the highest concordance. cases without an anatomic obstruction — The Blaivas-Groutz nomogram overestimates — MRI of the central and peripheral nervous system obstruction is the most commonly utilized radiological method — Not to be used as the sole definition of BOO to reveal certain neurological diseases — Akikwala et al, 2006 — MS, tumors, vertebral congenital and acquired pathologies

Concentric needle EMG of the external urethral SPECIAL TESTS sphincter — Bladder-cooling reflex; the ice water test — The test that diagnoses Fowler’s syndrome (1985) — show value in the diagnosis of NLUTD and in the differentiation between reflexic and areflexic neurologic — The EMG abnormality was called “decelerating bladder (LOE 2, ICI 2013). bursts and complex repetitive discharges” — Bethanechol supersensitivity test — a muscle membrane disorder and, therefore, a — may contribute to overall evaluation of neurologic LUT primary disorder of sphincter relaxation rather than dysfunction. (LOE 2, ICI 2013) inappropriately timed sphincter activity that occurs in — Sphincter EMG neurogenic detrusor-sphincter dyssynergia as the — can be valuable in the diagnosis of patients with neurologic cause of urinary retention. bladder dysfunction (LOE 2, ICI 2013). — Others: Nerve conduction studies, SSEP — Recommendation of grade C, ICI 2013

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Concentric needle EMG of the external urethral sphincter Concentric needle EMG of the external urethral Normal resting sphincter interference pattern with 3 or Increasingly — More than an involuntary sphincter contraction, 4 motor units expanding time over the years thinking evolved to include the firing tonically base from 30 to 3 mseconds per concept that the involuntary contraction of the division, so that sphincter has a reflex effect inhibiting detrusor wave form of contractions. complexes firing repetitively become apparent — The trigger is not known: Hormonal disturbance and form burst (progesteron deficiency in PCO), opiates, childbirth discharge (top) etc…?

— Should be spared to unexplained persistent cases

What is found after completing the evaluation? The answer depends on in which setting we are working.

What is found after completing Psychogenic urinary the evaluation? retention (PUD) — 65% reported an associated and possibly contributory factor Many patients are mistakenly labeled with involving the onset of retention. — — 35% spontaneous psychological retention — In two-thirds of cases it was an operative procedure. — However, acute FUR may manifest a conversion — preponderance of gynecologic procedures of the overall symptom operations performed. — Miscellaneous operations were diverse and included ear — regarded as a psychosomatic disorder of the bladder surgery, knee operations in 2 women, breast lumpectomy, due to neurosis/psychosis appendectomy and a shoulder operation. — described more frequently in young adult females — Childbirth, %15 with history of childhood enuresis and disturbed — Of these women 13 undergone vaginal delivery, including 6 with epidural anesthesia social backgrounds. — Other: 7%

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High-level of comorbidities in PUD Fowler’s syndrome is intriguing — The characteristics of urodynamics in PUD are — Of 62 patients with Fowler’s syndrome, 50% had increased bladder sensation during bladder filling unexplained chronic pain syndromes, and underactive/acontractile detrusor during — 19% of these were taking opiates. voiding. — None had DO or DSD — Abdominopelvic surgery with general anesthesia was the leading trigger (35%). — Regarding neuropsychiatric aspects, PUD is usually accompanied by more obvious psychogenic/ — 24% had ‘‘functional’’ neurological symptoms such psychiatric features. as non-epileptic attacks or leg weakness. — The majority of patients had conversion disorder or — 30% had psychological symptoms anxiety disorder.

An algorithm for the evaluation of FUR Conclusions

Initial evaluation: — The multi-factorial etiology of FUR is complicated Detailed history, physical examination, uroflowmetry and PVR measurement, urine analysis and culture, urinary tract ultrasound, renal function tests and poorly understood. Neurology, gynecology and psychiatry consultations, if necessary at any point — A considerable amount of pts with FUR have transient causes that can be diagnosed by a Persistent FUR structured clinical evaluation. Transient FUR

Start CIC Consider indwelling cath in the frail — CIC with elimination of transient causes will be enough to cure half of the patients.

A good quality (video)urodynamic study and cystoscopy

Treat the transient causes Neurogenic bladder/sphincter Obvious anatomic causes dysfunction Idiopathic retention

Further evaluation for Fowler’s Consider surgical correction Manage the NBD Syndrome or psychogenic urinary retention

Conclusions Do not…… — A good quality (video) UDS and cystoscopy should — Do not perform excessive urethral dilatation be considered in persistent FUR — Most common cause of female urethral stenosis is iatrogenic — A multidisciplinary teamwork is favored: — The most common urodynamic finding in FUR is — Urologist detrusor under-activity — Physiotherapist — Neurologist — Do not label idiopathic cases as psychogenic — Gynecologist without completing the psychiatric and neurological — Psychiatrist work up — Gastroenterologist/general surgeon

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Thank you

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Management of Female Pathogenesis *Likely major contributory fa Causes of female Retention Type Causes Idiopathic ?Normal Ageing* Urinary Retention ?Unknowncauseinyoungerpopulation*  ANATOMICAL  FUNCTIONAL - Medical and Surgical Neurogenic Parkinson’s Disease  Gynae; POP, fibroids  Underactive Bladder Diabetes  Post surgical  Bladder neck obstruction Guillane-barre synd rome Multiple sclerosis  Urethral stenosis/  Pseudodyssynergia Christopher Chapple Spinal- lumbar disk hernia / spinal cord injury / diverticulum Consultant Urological Surgeon  Neurological congenital Myogenic Bladder outlet obstruction*  Ureterocoele  Fowler’s syndrome Sheffield Teaching Hospitals Diabetes* NHS Foundation Trust  Foreign body Iatrogenic Pelvic surgery Radical Prostatectomy UK Radical Cystectomy Radical Hysterctomy Anterior Resection, abdomino-perineal resection

Men and w omen:urinarycatheters Potential Pathophysiology 5th International Consultation on Incontinence Paris: February 2012

Management using Continence Products • 1 ver yl arge r etrospecti ve study (25k SCI pts) showed that use of CIC has i ncr eased over the last 30 years but use of Committee 20: Alan Cottenden (UK), CIC and sheaths were more difficult to sustain than IDC. Mandy Fader (UK), Cheryle Gartley (USA), Daniela Hayder (Ger) and Mary W ilde (USA) • 1 large survey (719 US hospitals) showed that most catheter placements were not tracked and ‘reminders’ to Consultants: Donna Bliss (USA), Brian remove were rarely used. Buckley (Ire), Joan Ostaszkiewicz (Aus) • 1 small RCT (supra-pubic vs CIC post uro-gynae surgery) : no ‘clinical’ difference.

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Parasympathomimetics Pharmacological Options Surgery

 Paraympathomimetics  Trans urethral resection of  Alpha Blockers prostate  Intravesical therapy – prostaglandins  Intrasphincteric Botulinum Toxin  Sacral Neuromodulation None successful  Detrusor Myoplasty Recommendation D level 2/3

*UUB-Underactive urinary bladder, WG-Wertheim-Meig Barendrecht MM, Oelke M, Laguna MP, Michel MC. BJU international. 2007 Apr: 99:749-52

Causes of female Retention Conservative Treatment Options Definitive Treatment Options

 ANATOMICAL  FUNCTIONAL Midurethral Synthetic Sling Traditional Slings   Gynae; POP, fibroids  Underactive Bladder Watchful waiting  Sling incision  Sling Incision (PV sling)  Post surgical  Bladder neck obstruction  Intermittent catheterization  Urethral stenosis/  Pseudodyssynergia  Indwelling catheter  Sling loosening (early)  Urethrolysis diverticulum  Neurological  Pharmacotherapy to control associated  Transvaginal  Ureterocoele  overactivity Fow ler’s syndrome  Urethrolysis  Retropubic  Foreign body  Dilation (??) – I do not recomend  Suprameatal (infrapubic)

 Cut suspension/sling sutures  No published peer-reviewed series

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Technique of Mid Urethral Sling Loosening 1-2 weeks Autologous or Biological Sling Incision Autologous or Biological Sling Incision

 Infiltrate anterior vaginal wall with 1% lidocaine  Inverted U or midline  Freeing of the sling  Open vaginal suture line incision from the underlying urethra  The sling is identified and hooked with a right-  Isolation of sling in the  May require sharp or angle clamp midline blunt dissection  Spreading of the right angle clamp or  Incision of the sling  No perforation of downward traction on the tape will usually the endopelvic fascia loosen it (1-2 cm)  If sling cannot be  No freeing of the urethra from the pubic  If the tape is fixed, it can be cut identified, proceed with formal transvaginal bone  Reapproximate vaginal wall urethrolysis  Closure of the vaginal Vic Nittis personal communication From: Nitti et al: Urology 2002;59:47-52 w all From: Nitti et al: Urology 2002;59:47-52

Obstructing Midurethral Sling at 11 Midurethral Synthetic Sling Incision Obstructing Midurethral Sling months Complete Retention at 3 months

• If the sling is difficult to identify, can go lateral to the midline especially for TO slings • It is critical to identify the sling with certainty (consider pathologic confirmation) Illustrations from Vaginal Surgery for The Urologist Nitti VW, Rosenblum NBrucker BM Elseiver, 2012

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Outcomes of Midurethral Sling Revision for Voiding Early vs Late Midline Sling Lysis Results in TVT Take Down Results Dysfunction: Multicenter Retrospective Study Molden, S et al FPMRS 2010;16:340-44 Greater Improvement in LUTS N Type Success South MMT, et al Am J Obstet Gynecol 2009;200:564.e1-564.e5  175 patients (70% RP and 30% TO)  112 women of which 74 (66%) has early lysis Klutke, et al 1* 17 Midline Incision 100% normal emptying  54% cut (mean 71 days) < Rardin, et al 2** 23 Midline Incision 100% normal emptying  29% excised (mean 102 days) 1 year vs. 38 (34%) who had late lysis > 1 year Loosening 30% complete, 70%  18% pulled down (mean 9 days) partial r eso lutio n of storage sx

* Recurrent SUI in 6%  Outcomes ** Significant recurrent SUI 13%  Voiding symptoms resolved in 81% Resolution of VD 26% recurrent SUI, but significantly better than prior to TVT independent of  Storage symptoms resolved in 75% method and timing of  De novo SUI in 21% revision SUI less likely with  De novo OAB in 12% 1. Klutke C, et al. Urology 2001;58:697–701. early revision 2. Rardin CR, et al. Obstet Gynecol 2002;100:89 8– May be the patients more than the timing 902.

Traditional Sling Incision Formal Urethrolysis: Indications Urethrolysis - Anatomy Results after Sling Surgery N Type Success SUI  Failed sling incision (any material)  Urethra may be fixed to the pubic bone w ith Nitti, et al 1 19 Midline Incision 84% 17% dense scar tissue  Inability to identify autologous or Amundsen, et al 2 32 Various 94% retention 9% biological sling 67% UUI  Goal of urethrolysis is to completely free & Goldman 3 14 Midline Incision 93% 21%  In certain cases where there is consideration to mobilize urethra another sling in the same setting

1.Nitti VW , et al. Urology 2002;59:47–52. 2.Amundsen CL, et al . J Urol 2000;164:434–7 3. From: Nitti and Raz: J Urol Goldman HB. 2003;62:714–8 1994;152:93-8

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Transvaginal Urethrolysis Transvaginal Urethrolysis

 Sharp and blunt  Place penrose drain  Inverted U incision dissection freeing the around the urethra urethra from the  Lateral dissection undersurface of the above periurethral pubic bone fascia  Index finger placed  Endopelvic fascia betw een pubic bone and sharply perforated and urethra retropubic space entered From: Nitti and Raz: J Urol 1994;152:93-8 Illustrations from Vaginal Surgery for The Urologist Nitti VW, Rosenblum NBrucker BM Elseiver, 2012

Transvaginal Urethrolysis Optional - Interposition of Martius Retropubic Urethrolysis Suprameatal Urethrolysis Flap  Mobilization of urethra by sharp dissection  Curved incision above the urethra  Restore complete mobility to anterior vaginal w all  Paravaginal repair  Interposition of omentum between urethra and pubic bone

From: Webster GD and Kreder KJ J Urol 1990;144:670-3 From: Petrou SP et al: J Urol 1999;161:1268-71

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Urethrolysis Results Repeat Urethrolysis Suprameatal Urethrolysis N Type Success SUI Scarpero, et al, J Urol, 2003;169:1013-1016 From: Petrou SP et al: J Urol 1999;161:126 65% 0  Sharp dissection of Foster & McGuire 48 Transvaginal Urgency Incontinence Stress Incontinence urethra and bladder 71% 0 neck off pubic bone Nitti & Raz 42 Transvaginal 72% 3%  2/16 (12%) resolved  4/22 (18%) de novo  Pubourethral, Cross, et al 39 Transvaginal pubovesical “ligaments” SUI 84% 19% incised Goldman, et al 32 Transvaginal  11/16 (69%) improved-  Retropubic space 67% 3%  entered Petrou, et al 32 Suprameatal required anticholinergics 2 had persistent SUI  Lateral attachments left 93% 13% Webster & Kreder 15 Retropubic  Care to avoid injury to  3/16 (19%) no  5 w omen had bulking autonomic nerves 83% 18% improvement and 4 w ere improved  Martius flap Petrou & Young 12 Retropubic 8-71 78% 14% Carr & Webster 54 Mixed

Interstim for Persistent OAB Obstructing Sling Algorithm Transvaginal Urethrolysis After Early Intervention Prior Failed Urethrolysis Symptoms After Urethrolysis (Mid urethral synthetic sling) McCreary and Appell Int Urogynecol J, 2007;18:627-633 Starkman et al, Int Urogynecol J 2008; 19:277–282 Yes No  23 procedures in 21 patients  8 women who failed at least 2 Failure  Mean 1.72 prior procedures anticholinergics Sling loosening Watchful waiting or cutting - office  18 patients with obstructive  Mean time from urethrolysis to SNM 11.9 symptoms/findings months (3-26) Transvaginal Sling incision -OR  13 cured (72%)  6 responded mean f/u 15.7 months (6-34) Failure   9 of 14 catheter dependent patients cured (64%) 3 OAB symptoms completely resolved Transvaginal Urethrolysis  PGI-I “very much improved”  17 with storage symptoms Failure  3 improved (1-2 UUI episodes/week)  10 cured (59%)  PGI-I “much improved” Repeat Urethrolysis (possibly retropubic)  6 improved (35%)

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Abnormal electromyogl"aphic activ ity of the urethral sphincter, voiding dysfunction, a nd polycystic ovaries:A new syndrome?

Summary Causes of female Retention O u e J Fo wk ' .r, Tln lOth )' J ChriJ1m1s 1 Oiriitopher R Chapple, Helen Fitzmaurice l arkhoust, Roger S Kirby, Howard SJac:OOs 8 \J \'OIJJM.t 291 J Dt:Cl!M IU 19$8

1haan o n mlo n ries (man '-olunw S•8 ml(-4·6 Kl1 ·J)),  A p o ttt1 tW aS50ci:a.tio• Ntwtt1 1 •bltonW d tttto with a highly « anddmst- «nlr.d scronw and Clinically significant obstruction after sling surgery  ANATOMICAL  FUNCTIONAL iny op:aphic ac tiYiry -Wt i., dccclt.rati., burl• n u merou s (> 10) pnipbcnlly loottcdtl. Abflomat p o ly cystic o ·sy n d ro me nuy be th e d i not1i1.•Th b  Gynae; POP, fibroids  Underactive Bladder c k arom y ognp tl c ac tiv ity wu foufti•d )J. U Jtra co n d itio n is asr.o cia1td wi1h ir u : rs cd co n ccntr.itk ln s aoo o g rapb y of lh-c-o v ari es ia22 of ... c )} wo • cn ctf 1-.ir.:u la.1in g an d nt and h n in itin g hOfrn ()I' occurs even in the most experienced hands sh o wtd th.:11 1 4 h ad poly cystic o v 1 rie1 . Of th e o th t r (\\•hh no[r:nal concencr.arions of follicle .s1inu1laon3 eig h t wo m en, t wo b ad h ad o o p h o " cto mi c• ,oneb ad horrn-:inc) and, in 30% of cases, h.yperPfOlllclinh ioJ\11.)' diverticulum  Neurological polycystic ovarysf..:lro mit. VidtoC)'Ao.ttrocraphy Ill lht i'iiickDtscx ff()Spital during 19&28 ror tlc<'tro techniques, are successful in restoring emptying and ia 17of tH wo• c.nwlrtoweree.aa.UN'd by l d t myograph)' of the: urethral sphjnctn. 1M 1nd.caL11." 1 p a y sb o wd low flow r M H a.ct ._IPru ichaa.I wu recent.ion olurioc or dyd'unction o''Otdias( ·The  Ureterocoele  vohmits of winoc: afttt • k1uritiM in lZ w o . c. wk referring doctors •-u c: n 'ltt o{our intnut in the: relieving LUTS in a majority of cases Fowler’s syndrome c:oald Yo icl, tk otba ive tLa-n., C' wiauy d ccmmyo g raph ic abfto n n alicy ,1 and p aticnl were m a. deatly td ieatd . A sp ceub tift •JPOtMsis fo rtM obMrv ed u so cia· &ch pa\ C u n d trw to l tk c' lro n t)' (lln :phy of  Some studies “suggest early rather than late is better  Foreign body tioa of impaired YOidia&. abltorilut ck:ctto• ro che u r c -$ p llin ctn ..-i\b a o o o cmtrtC n«Jk c activ ity oltllie .,;,.,,ry $pllinc:te:r. aAd pol_y· d«t:rock,""'" and abnormO\I elttt ro myo p tp h ic 1M'.l1V1t7 cystic ovaric• i.s adYJ.nced, bilM d a.lit RlarlY'C (that is. d «c:krating bunts and<' Ompk x ttpetith-c p ro g c$ 1 cro •t d d cieKJ tlliat charKterkta IJic poly · d iscb arg f!S) w.ts found iol. Pelvic uhra'.\Oeqraphy cystic o v ary sy o d ro cM. Pro cQtcroM 1 t:abil» c-s was ciarriied o ut i.n 22 ortb c: 3.3 wonM:"n (1ht o th er 11, mt.mb.tUts,a.o d its d cpk tio n • iaht p cNlic cph aptic who had bttl'I early subjectsaoo •sklCondiry rc:fttr.tl tru smissio n o f iapu Jscs tween in u cle fib 1 ts d ffQln t.Qng:d i s t a. n couldno1be rtai1ilyrtatllc:d , wc:tt  The diagnosis is most often made based on clinical lht causck of t..e 1 1 tttlilnl sp lilirw:ter , &iv in1 riwlo nut avaibiblt), Uhra graphy "'II.$perf'orin""db)'one th e abn o n u l cl ett. ro •Y<>&r-.p hk aetlv ...y . Th is r11ay o( lWO cicperi-l;O(;cd r..J i0gr.1phm wilh a 3 i\ill i t.>ng imo :air reta•11.ion or th e sp h ilict er, rtt Wlln a In k>w focu:scd transducer auachl.-d 10 u.n Ale>ko 720 hi gh grounds rather than testing Row rates of IU' inc, in compaet e empty ln 11 of tb e r1 . lu tton !S«lor scanner. A h i!ilo ty of l'IClvic opc:r.• b ladd er, and , fin ally , u rin ary rettad o 11. 1 jonsor m en s1tu2 I im::gul:t.rh y and th e p rC!IC:llOC: o( lli11u1ism oraenie'A' ett reco rded .

Treatment of Fowler’s syndrome SNS in Fowler’s syndrome Long term outcome of SNS

 Stop all opioid analgesic drugs  FDA/ NICE supported  5 year data from 17 centres; 31 patients  No established drug treatment  Some patients show marked improvement  ISC fell from 5.3 (+/- 2.8) to 1.9 (+/- 2.8)  Alpha-1 antagonists and viagra poor outcome  Physiological mechanisms unclear  Reduced mean catheterised volume  PDE4 inhibitor theoretical potential  Cost  At 5 years clinical success rate 58% (at least 50%  Self catheterisation very poorly reduction in symptoms)  Patient selection tolerated; Mitrofanoff procedure  78% of people responding at 1 year w ere still  Sacral nerve stimulation responding at 5 years

Van Kerrebroeck et al. J Urol 2007; 178: 2029

7 03/06/2015

EMG-negative Fowler’s Causes of female Retention syndrome  ANATOMICAL  FUNCTIONAL  Gynae; POP, fibroids  Underactive Bladder  “Non-Fowler Fowler’s syndrome”  Post surgical  Bladder neck obstruction  Baclofen  Urethral stenosis/  Pseudodyssynergia  Supportive measures and follow up diverticulum  Neurological  Mitrofanoff procedure  Ureterocoele  Fowler’s syndrome  Foreign body

U-Shaped Circumferential

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Pre-operative assessment

 How large is it?  Is it asymptomatic? Only treat if symptomatic  Physical examination  ? Cystocoele  ? Stress incontinence ? Need for urodynamics  Is there infection present?  MSU

Female urethral diverticula Excisional Surgery -tips Treatment  Palliative  Sim’s Position rather than standard lithotomy  Endoscopic incision  Self retaining retractor –eg Parkes  Curative  Good light  Marsupialisation  Suction  Excision  Infiltrate with fluid ( adrenaline)  Excision &Young – Dees reconstruction Urodynamic films and subsequent MRI –note extension behind bladder

9 03/06/2015

Technique

 ‘U’ Flap of vaginal mucosa  Dissection of the diverticulum  Closure in layers – careful repairof the urethra  Martius flap  Overclosure of repair  Mitigate against stress incontinence  Facilitate subsequent sling procedure

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11 03/06/2015

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Post-operative Management

 Remove vaginal pack & Martius donor site drain at 24 hours  Suprapubic catheter  Leave urethral catheter for 2-3 weeks  Oral antibiotics until catheter removed

Post-operative complications T A B L E 6 _ C <>.- .t.i.. - . e c : e S t a t " t . I s <>-f 50 <> m e . - . A f t e r U r e t h r a l I> i v e r t i. c : a . a l e c . "t<>my ' - " i .th a ea F < > l l <> - ._.P <>£ 68  Stress Incontinence <> t .h s P r <>c::.ed...a re:  Urethrovaginal Fistula Di- v e r t i c t . . i l e c " t o m y a o n e ( 2 5 vvom e n ) C o n t i n e n t: I 2 1 ( 8 4 -o/o ) *  n con t i n ent 4 (16 % ) Recurrence of D e r r - t . . . t s o r in sta b i l ty 1 ( 4 % ) - t S t r e s s in c o n t i nen ce . 3 2 o /o ) T D iv e r t i c u l e c t o m y a n d ( 1 diverticulum b ladder n e c k s u s p e n s i on ( 2 5 V J C > m e n )  Urethral stenosis Con tin e n t: 1 8 ( 7 2 o /o) * In con tin ent 7 D e t r u s o r i n s t a b i ity (1 2 8( 4o /o)o/o ) :j: S t r e s s in c o n t i n e n ce 6 * D r y o r r e q (uir 2i n 4g %a ny) -t in im al i nco ntin e n ce n ot "Tlnpac odn ft o i n r epn rce o t er c e t q i ou inr i _n g h a n t v . J o f e v v e r p a d s p e r d a y f o r p r o t . e c t i o n _ + I n c o n t i n e n ce req uir in g t . h an o m o r e p a d s p er d a y f o r p r o t e c t io n _

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Results Dysuria 75°/o

69 p1atientsunderw1ent UD repair, Pelvic pain 72°/o

the maj ority were mi1d urethral Dyspar1eunia 510°/o (46°/o) or d stal (31o/o) often multi

Frequency 1 lobulated. Media.n a1ge was 40 46°/o tr :O y·1ears. Ave rage size was 12m m Pus PU 44°/o (ra.nge 8-42m m )..26 patientshad SUI 38.°/C0 pre-existing SU . 3 of these had1

fistu la 1e aft1er failed urethral surgery, Urgency 34°/o . ] ] 6 were recurrent UD, and 2 had1 D 6 Infection received Tension-free Vagina 34°/o

Tapes prior to r1eferral.

Summary Summary Surgical Options – Vaginal Flap

 Common prevalence of the condition –  If symptomatic excise  Vaginal Flap urethroplasty first described in incidental finding on scanning  Prone position 1935 Harris Surg Gynes Obstet 1935 61: 366  Uncommon clinical condition  Martius Flap Modified Ellis and Hodges J Urol 1969 102:214  Probably follows infection of  Subsequent autologous sling periurethral glands  Urethral catheterisation  ‘U’ flap in anterior vaginal wall  Usually mid/distal urethra  Stricture incised  Flap advanced avoids tunneling

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fJ N e·u r o u r ology and Ur od y nam ics 29 :S42- S45 (2010) l:t------R E V I E W ARTICLE -

V a g in a l Flap U reth ro p la s ty f or Fema le U reth r a l St r ic t u r e D is e a s e

B. A n n G o r .mJ ey · Oartm ot.1th H i t c hc oc k M edic al C enter , Lebanon, N ew H am ps hir e

TABLE I. Preopezative Patient Characteristics p t no. Symptoms Prior treatments Incontinence PVR Catheterizable Urethral caliber (type) inoffice (Fr).a

1 Urge/frequency Dilation, u rethrotomy Yes (urge) 240 No 4 2 Urge/frequency. renal failure Dilation, urethrotomy No 500 No 8 3 Urge/frequency Dilation, excision of urethral polyp No 10 Yes 10 4 Urge/frequency Dilation. excision of urethral polyp Yes (stress} 10 Yes 10 5 Urge/frequency. infections Dilation No Min No 8 6 Urge/frequency Dilation Yes (s tress) 10 Yes 12 7 Urge/frequency Dilation No NR No 10 8 Urge/frequency Dilation Yes (stress} NR Yes. difficult 12 gb Urge/frequency, retention Young/Dees/Leadbetter procedure No 310 Yes. difficult 12 lOb Urge/frequency Dilation, hx of pelvic RT Yes (urge) 50 Yes 12 llb Urge/frequency Dilation No Min No 10 12b Urge/frequency, retention Dilation, urethrotomy No 220 Yes, difficult 16RR RR, red rubber catheteL SUI was confirmed in three patients with urodynamics. When a UDS catheter could not be placed the type of incontinence wasdetermined by history. "Measured in the office if a catheter could be placedbut otherwise measured in the operating room. bAdditional patients.

Dorsal vaginal graft urethroplasty forfema le Dorsal onlaylingual mucosa!graft urethroplasty urethral str icture disease for urethral strictur es in women BI JUIU INl ERNAfl O HA l BUI Steven P. Petrou, Alexand ra E. Rogers, Alexander S. Parker, Girish K. Sharma,Ashwani Pandey, Harbans Bansal, Sameer Swain, Kristin M. Green and J. William McRoberts* Suren K. Das, Sameer Trivedi, Udai S. Dwivedi and Pratap 8. Singh Deportment of Urology, Institute ofMedical Sciences, Bonoros Hindu University. Varanasi.Uttar Pradesh, Indio Departments of Urology, Mayo Clinic, Jacksonville, FL and university of Kentucky, Lexington, KY, USA Accepted for publication 5June 2009 Acctpttd for publication 29 February 2012 P Urethra Incontinenc Pt Follow up Urethral Incontinence P t e Gl-l Postop n Ag caIibrarion Itype) no !months) calibration (type) ore dilations Inall, 15women (mean age 42years) witha o e (Fr) (Fr) s N c history suggestive of urethralstricture who y 1 55 17 N 1 6 26 Y [Urge) 2 had undergone multiple urethral dilatations Thepreoperative mean maximum urinary 3 46 14 Y (Urge) 3 12 26 3 y 2 70 18 Y (S tress) 2 6 28 NN 1 and/or urethrotomy wereselectedfor dorsal ftow rate of 7.2m s increasedto 29.87mlJ 4 70 16 Y (Stress} 4 18 24 2 N N onlay LMGurethroplasty after thorough s.26.95 m sand26.86 ml/s witha'normal' 5 73 16 Y (Urge} 5 19 24 3 fiow rate curveat 3, 6and 12 months N Y+ CIC evaluation, from October 2006 to March 6 71 14 Y (Urge} 6 11 24 4 follow-up,respective.One patientat the3- N N dissectedandurethrotomy was done atthe 7 39 14 7 26 20 monthfollow-up had submeatal stenosis N N N 12 o'clock position across thestrictured ...... 8 75 16 Y (Urge) monthlyintervals.At the 1-yearfollow -up, 8 27 20 Y (Urge) N segment TailoredLMG harvested from the none ofthe presentpatientshad any 9 52 14 Y (Urge) 9 33 20 Y !Urge) 2 N ventrolateral aspect of the tonguewas then neurosensorycomplications,urinary 10 62 14 Y 10 46 24 Y 5 N sutured to theurethrotomy wound over an incontinence,or long-termfunctional/ !Stress/Urg (Stress/Urge N 18 Fsiliconecatheter. aestheticcomplication at the donor site. e) ) 11 54 14 Y 11 46 22 Y !Urge) (Stress/Ur CIC,cleanmterm1ttenccorhensation. ge}

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Conclusions Surgical Approach to the Urethra  Female outlet obstruction is a varied group  No guidelines or recommendations on this  Anatomical and functional causes at present.  Post surgical retention; examination findings can guide  Evidence would suggest either a dorsal ot suitable intervention ventral approach.  Urethral stenosis manage as conservatively as possible  Consider Martius if intend inserting a sling  Urethral diverticulum – manage with due attention to  Consider sling at first operation if severely sphincter incontinent otherwise I favour a two stage  Fowler’s syndrome; approach.  young women with painless retention  Long term follow-up is important  High MUCP and typical EMG

16 Urologia 2013 ; 00 ( 00 ): 000-000

REVIEW

Urinary Retention

David Hernández Hernandez, Ricardo Bernardez Tesouro, David Castro-Diaz

Department of Urology, University Hospital of the Canary Islands, University of La Laguna, Santa Cruz de Tenerife -

Department of Urology, University Hospital of the Canary Islands, University of La Laguna, Santa Cruz de Tenerife - Spain SpainDepartment of Urology, University Hospital of the Canary Islands, University of La Laguna, Santa Cruz de Tenerife - Spain

Urinary Retention

Urinary retention, defined as the inability to void, is a common medical problem. If unidentified and/or untreated, it may become a serious condition that can lead to kidney damage or urosepsis, compro- mising the patient’s life. Acute urinary retention (AUR) is usually easy to identify and to treat as patients usually complain of hypogastric pain and anuria. Proper bladder drainage with urethral or suprapubic catheter is the first line of treatment, with posterior studies to determine the cause of retention. Chronic urinary retention (CUR) is often much more difficult to identify. It is invariably linked to in- creased post-void residual urine (PVR), but its asymptomatic nature makes it often a hidden condition. There is a wide range of intrinsic and extrinsic, obstructive and non-obstructive causes affecting the lower urinary tract, which can lead to urinary retention. Due to the differences in urinary physiology and in order to simplify diagnosis and management, these are usually studied separately in men and in women. Management consists of a variety of options depending on the cause of retention, including conservative treatment, drug therapy and several forms of surgery. In this review, we make an overview of the main causes of acute and chronic urinary retention in men and women, focusing on the main aspects of diagnosis and management.

Key words: Urinary retention, BPH, Bladder outlet obstruction, Detrusor underactivity, Dysfunctional voiding, Fowler’s syndrome

Accepted: October 9, 2013

Introduction loaded and the retrograde increase of pressure leads to acute renal failure. Urinary retention is a common medical problem. It is de- fined as the inability to void, totally or partially. Depending Chronic urinary retention (incomplete voiding) upon the time of symptoms developing, urinary retention can be classified as acute, usually also total, and chronic, This is a more relative term that describes a situation in usually partial. which the patient is progressively unable to full empty the bladder. It is described as incomplete emptying or elevated Acute urinary retention (AUR) post-void residual. These are huge relative terms, so that identifying this condition is more complex. Symptoms of The patient presents, suddenly, a complete inability to this condition are slow stream, sensation of incomplete void. It is a urological emergency that causes an intense emptying, suprapubic pain or discomfort, repeated urinary hypogastric pain due to bladder overdistension. If untreat- infections and even rarely pure storage symptoms (i.e. fre- ed with bladder drainage, the upper urinary tract is over- quency or urgency).

© 2013 Wichtig Editore - ISSN 0391-5603 1 Urinary Retention

Normal functions of the lower urinary tract are storage and lower urinary tract function, urinary retention is usual clas- timely elimination of urine. These are dependent upon the sified as urinary retention in males and in women. activity of two functional units in the lower urinary tract: a reservoir (the urinary bladder) and an outlet consisting of the bladder neck, urethra and striated muscles of the URINARY RETENTION IN MALES external urethral sphincter (1). During bladder storage, the bladder outlet is closed and the detrusor is relaxed to main- Acute urinary retention in males is invariably linked to BPH, tain low intravesical pressures. During voiding, the detru- being this condition the main cause. Three main risk fac- sor contracts and the bladder outlet relaxes to allow mictu- tors have been identified to develop acute urinary reten- rition (2, 3). This process requires coordinated work of the tion in men with BPH (4): presence of moderate to severe bladder smooth muscle (detrusor muscle) and the striated lower urinary tract symptoms, depressed peak urinary flow muscle from external urethral sphincter, and integrity of the (less than 12mL/s) and an enlarged prostate (greater than anatomic structures of the bladder outlet (bladder neck, 30mL). Other factors, such as post-void residual (PVR), urethra and urethral meatus). Taking this into account, we age and PSA serum concentration also have been linked can understand that urine retention can be due to bladder to increased risk of AUR (6, 7). outlet pathology (obstruction), inefficient bladder contrac- AUR in males can present in two different forms, depend- tion (detrusor underactivity) or the combination of both. ing whether a trigger factor can be identified, with different In men, urinary retention is frequently due to bladder outlet future prognostic and treatment implications (8): obstruction (BOO) as a consequence of benign prostatic Spontaneous AUR: no trigger factor identified, being part hyperplasia (BPH). AUR affects between 2.8-6.8 per 1000 of the natural history of BPH and usually after a long period men, with approximately 10% of men in their 8th decade of lower urinary tract symptoms. After a spontaneous AUR, suffering at least one episode. This proportion increases to 15% of patients suffer another episode and up to 75% will one third of men in their 90s (4). In women, the epidemiol- have surgery due to this condition. ogy of this condition is not well known and much worse Triggered/precipitated AUR: urinary retention is preced- described. ed by a trigger factor such as surgery/anesthesia, pain, To simplify diagnosis and management, and due to the dif- constipation, acute medical illness, urinary infection and ferences in the nature and physiology of male and female drugs. After a triggered AUR only 9% presents with an- other episode and 26% requires surgery. In a study by Cathcart et al. with 165,527 men who had been Table I - Etiology of urine retention admitted for primary AUR, it was reported that men with spontaneous AUR were 5-fold more likely to have recurrence - Prostatic obstruction (BPH, PCa, Acute prostatitis, prostatic ab- scess) within 6 months than men with precipitated AUR (9). - Bladder obstruction (bladder tumor, clot obstruction, bladder In 2005 Desgrandshamps et al (10) published an epidemio- stones, high-degree cystoceles, bladder neck sclerosis) logical study with 2618 patients suffering from BPH and - Urethral causes (urethral strictures, urethral tumors, hypospadias, detailed the etiology of AUR in these subjects. 71.6% of epispadias, urethral meatus stenosis, urethral stones) patients (1875) in this study suffered spontaneous AUR, - Gynecological causes (ovarian or uterine tumors, high-degree pel- vic organ prolapses, post-partum urine retention) while 28.4% (743) had precipitated AUR. The main precipi- - Anorectal causes (fecaloma, rectal tumour, pain due to anorectal tating factors described in this study were surgery with lo- surgery, perirectal abscess) coregional or general anesthesia, constipation with fecalo- - Post-operative urinary retention (multifactorial and relatively fre- ma, drugs, acute anorectal pain and acute medical illness. quent in pelvic, vascular and orthopedic surgery) The initial management of AUR must be bladder catheter- - Neurological causes (spinal cord lesions in acute phase, metastatic spinal cord compression, demyelinating spinal cord diseases, pe- ization, either transurethral or suprapubic, to avoid poten- ripheral neuropathies) tial dangers such as acute renal failure, urinary sepsis and - Drugs (α-adrenergic, β-blockers, anticholinergics, antidepres- to alleviate pain and discomfort. There is no consensus on sants, neuroleptics, opioids) what is the best method of catheterization, but the feasibil- - Psychogenic ity of urethral catheterization makes it more frequent world- (Adapted from Reference 5) wide (11). A survey of 410 urologists in the UK shows than

2 © 2013 Wichtig Editore - ISSN 0391-5603 Hernandez et al

98% of them choose urethral catheterization as first-line infections) and hospital stay (10, 15). Alpha-blockers plus treatment for AUR (12). Both methods have advantages TWOC after 3 to 7 days has a success rate over 50%, with and disadvantages. Urethral catheterization is cheaper and the possibility, if it fails, of a second attempt with a success simpler, available in all kinds of health centers, and can be rate of about 25% (10). performed by most doctors and other health practitioners. 5-alpha-reductase inhibitors (5ARIs) also play an important A higher incidence of urinary tract infections and urethral in- role in the management of urinary retention. These drugs jury/strictures has been observed with this method of cath- decrease prostate volume and improve urinary symptoms eterization (13).Suprapubic catheterization (SPC), which is in the mid- and long-term. Although they have no role in much more used by French urologists [17% of them used acute phase (AUR), long-term double blind versus placebo it as a first-line treatment of AUR (10)], has also advantages studies such as the MTOPS and CombAT (17, 18), involv- and disadvantages. It avoids urethral damage and reduces ing more than 7000 patients during 4-4.5 years, showed the infection rates; a Cochrane review reported also about that the combination therapy with alpha-blocker and 5ARI decreased levels of discomfort, particularly in younger pa- (doxazosin + finasteride in MTOPS; tamsulosin + dutaste- tients. SPC allows also a trial of voiding without remove ride in CombAT) was superior to placebo than either ther- the catheter, avoiding re-catheterization if this trial fails. On apy alone in terms of AUR developing, symptoms control the other hand, it requires specialized training to minimize and the need of BPH surgery (BPH progression) This im- serious complications (i.e. 1-3% of bowel injury) It shows provement in disease control was specially marked in men also higher rates of hematuria, catheter blockage and in- with higher levels of PSA (>1.3-1.5) and greater prostate sertion failures (10).Once the bladder is drained a com- volumes (>30-40mL). plete history and physical examination, including digital Chronic urinary retention is also common in older adults, rectal exam, must be performed. Measurement of drained but there is a lack of a standard and precise definition [the volume of urine, serum creatinine and ions, investigation presence of PVR between 100 and 500mL has been used on urine infection and hematuria might be also performed. (19-22)] and also of well-designed epidemiological studies With these data, we have an initial overview about pos- about incidence and prevalence. It is usually painless and sible etiology, severity of clinical situation and possibility of almost asymptomatic from the patients’ perspective, and hospital or ambulant management. The presence of gross overflow incontinence is relatively frequent. In this situa- hematuria, urosepsis, acute renal injury, drained urine vol- tion the patient suffers from a painless full-bladder with ume >1L, significant post-obstructive polyuria, unusual urine leaks due to overflow. Of course this is a dangerous symptoms (severe abdominal pain, neurological) or inabil- situation with high rates of urosepsis and renal damage. ity to manage with an indwelling catheter advise against an Causes or diseases associated with chronic urinary reten- ambulatory care program (14). After the initial bladder de- tion in adults include neurologic conditions (Parkinson’s compression and studies, the most widely accepted treat- disease, stroke, multiple sclerosis, dementia), myogenic ment option is starting treating with an alpha-blocker and conditions (diabetic cystopathy, muscular dystrophies, de- attempting to remove the catheter after a variable period of trusor hyperactivity with impaired contractility, anticholin- “bladder rest”, which has been named TWOC (trial without ergic drugs) and chronic bladder outlet obstruction (BPH, catheterization). Age ≥70 years, prostate size ≥50g, severe urethral strictures, bladder neck contractures). lower urinary tract symptoms, drained volume at catheter- The management of this complex condition includes treat- ization ≥1000mL and spontaneous AUR favored TWOC ing the underlying cause whenever feasible (medication or failure, as shown in a study by Fitzpatrick et al., with more surgery for BPH, urethral strictures or bladder neck con- than 6000 men catheterized for AUR in France, Asia, Latin tractures), but in many cases the only option is intermittent America, Algeria and the Middle East (15). Adding an al- or permanent bladder catheterization. pha-blocker prior to TWOC almost doubles the possibility Detrusor underactivity (DUA), which causes poor or no of successful catheter removal, irrespective of the alpha- bladder contractility, is a frequent and poorly understood blocker used (15, 16). The timing of catheter removal has phenomenon that contributes to urinary retention. The In- also been an issue of discussion. It has been observed that ternational Continence Society defines it as “a contraction prolonged catheterization (>3 days) does not improve the of reduced strength and/or duration, resulting in prolonged rates of TWOC success while it increases morbidity (mainly bladder emptying and/or a failure to achieve complete

© 2013 Wichtig Editore - ISSN 0391-5603 3 Urinary Retention

bladder emptying within a normal time span” (23). It in- to be taken into account that there are rare cases reported, cludes decreased detrusor contraction strength and veloc- such as cytomegalovirus cystitis (28), eosinophilic cysti- ity, resulting in impaired bladder emptying efficiency. DUA tis (29), inflammatory nervous disease (30), incarcerated is present in 9-45% of older adults undergoing urodynamic gravid retroverted uterus (31), which offer variable charac- evaluation for non-neurogenic LUTS, and rates increase teristics to this entity.In order to properly empty the bladder with advancing age (24, 25). Multiple etiologies are im- during the voiding phase of the micturition cycle, a sufficient plicated, affecting myogenic function and neural control strength and duration of the detrusor activity is needed. Any mechanisms probably related to the ageing process. Man- kind of disorder affecting the strength or duration of the de- agement, diagnostic criteria and treatment of this condi- trusor contraction, an increase in the outlet resistance or the tion, as well as its relation and overlap degree with other poor coordination between the bladder (detrusor) and the urodynamic conditions, such as detrusor overactivity and bladder outlet (sphincter) may cause an insufficient empty- BOO, need to be further studied. ing or a urinary retention in women (32, 33).

Etiology of Female Urinary Retention URINARY RETENTION IN WOMEN Retention due to bladder outlet obstruction Urinary retention in women, in contrast to men, is rare and Pelvic organ prolapse diverse; diagnostic criteria are not agreed and the epidemi- gynecological causes ology is not well known. The reported male-to-female ratio Post-surgery for stress urinary incontinence on urinary retention is 13-1, and the incidence is approxi- Primary bladder neck obstruction mately 7 per 100,000 population per year (26). Forms of Urethral stricture urinary retention and bladder emptying disorders in wom- Meatal stenosis en include: complete retention, incomplete or insufficient Urethral diverticula emptying and elevated post-void residual. It may be acute Caruncle or chronic, symptomatic or asymptomatic as explained Lithiasis above. Ureterocele There are many causes of urinary retention in women, foreign body but we will be more emphatic on the two most common Tumor causes in the neurologically healthy women: pelvic floor Skene’s gland abscess dysfunction, or dysfunctional voiding, and primary bladder neck obstruction (27). Retention due to bladder dysfunction neurological disease Etiology of urinary retention in women diabetes Mellitus Pharmacologic There are anatomical and functional causes of urinary re- Aging tention in women. Anatomic causes can be related to iat- Pain rogenic procedures (urinary retention surgery or colorectal Infective/Inflammatory disease and gynecological surgery) and to abnormalities due to fowler’s syndrome obstruction by pelvic organ prolapse, gynecologic tumors, dysfunctional voiding caruncle, urethral diverticulum, ectopic ureterocele, etc.). detrusor external sphincter dyssynergia Urinary retention due to functional disorders is related to bladder dysfunction or bladder outlet dysfunction. Blad- Evaluation der dysfunction may be related to detrusor under-activity, Lower urinary tract symptoms in women show a poor cor- acontractile bladder or failure of sphinteric relaxation. Fe- relation with the underlying disorder; consequently, the male urinary retention due to bladder outlet dysfunction is evaluation should be carefully performed in order to make usually due to two main entities: primary bladder neck ob- a precise diagnosis (34). struction and dysfunctional voiding. Besides these, it has A thorough history has a very important role in the inves-

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tigation of urinary retention in women. Storage symptoms usually have a limited value in the clinical diagnosis; by diographic evidence of obstruction between the bladder contrast, voiding symptoms such as poor urinary stream, neck and the distal urethra in the presence of a sustained hesitancy, straining and feeling of incomplete emptying detrusor contraction of any magnitude, usually associat- are clearly suggestive of outlet obstruction in women. The ed with reduced flow rate or delayed flow (38). Using the voiding history should focus on both storage and void- Blaivas-Groutz nomogram BOO is defined by the pres- ing symptoms. Timing of the onset of symptoms can help ence of free Qmax ≤12mL/sec in repeated free flow stud- into the appropriate diagnosis. Past medical and surgical ies, combined with a sustained detrusor contraction and conditions may be essential. Defecation and sexual prob- Pdet Qmax ≥20cm H2O in a pressure flow study. However, lems must be addressed. Fluid intake and voiding diary the presence of obvious radiographic evidence of BOO can help. with a sustained detrusor contraction of at least 20cm of In cases of complete retention the bladder can usually be water and poor Qmax - regardless of free Qmax or inabil- palpated during bimanual examination. In these cases, a ity of void with the transurethral catheter in place despite full neurologic examination should be performed. An ab- a sustained detrusor contraction, may also establish the dominal, vaginal and rectal examination must be carried diagnosis (39). out searching for constipation or fecal impaction and ten- derness of the levator muscle complex. Possible causes Pelvic Floor Dysfunction (Dysfunctional Voiding) of anatomic obstruction of the bladder outlet like urethral diverticulum, pelvic organ prolapse or other gynecological Following the recommendation of the International Urogy- causes should be kept in mind as well. necological Association and the International Continence An upper and lower urinary tract ultrasound is important Society (40), the pelvic floor dysfunction is a term that can to rule out repercussions on the upper tract which might be applied to a wide range of symptoms and signs affect- compromise kidney function. Although the presence of ing bowel function, sexual function, urinary continence or residual urine volume does not necessarily give away the voiding. The term ‘Dysfunctional voiding’ identifies “an in- diagnosis of bladder outlet obstruction in women, it should termittent and/or fluctuating flow rate due to involuntary in- be looked upon as an important criterion in the presence termittent contractions of the peri-urethral striated muscle of relevant symptoms. during voiding, in neurologically normal individuals” (41). Urethrocystoscopy is an invasive but useful procedure in Incidence ranges from 4.2% to 46.4% (42). The mecha- the diagnosis of bladder outlet obstruction in women. Be- nism by which this alteration occurs is not fully under- cause cystoscopy provides therapeutic possibility, it should stood. In addition to obstructive symptoms, women with be used as a last diagnostic test. When the obstruction is dysfunctional voiding normally have higher prevalence of confirmed on urodynamic test, cystoscopy evaluation can storage symptoms such as frequency, nocturia and urgen- be used to determine the site of obstruction. cy (43). The average age at presentation is around 40 years The urodynamic test is the most useful test in the evalua- (44). Video-urodynamics may show the level of obstruc- tion of urinary retention and the gold standard to identify tion at the external sphincter or pelvic floor. Furthermore, the functional cause of bladder outlet obstruction. The use a spasmodic activity of the external sphincter can often of simultaneous fluoroscopy is very useful to identify the be seen during the fluoroscopic assessment.Treatment for level of obstruction (35). The suggested criteria for female this condition will depend on the severity of symptoms, as bladder outlet obstruction are Qmax of 15mL/s or less, there is no clear evidence that mildly symptomatic women combined with PdetQmax of 15cm H2O or more, with a absolutely need to be treated (33). In cases of urinary re- sensitivity of 80% and specificity of 83.1% (36). These cri- tention it is necessary to relieve the obstruction and to treat teria were revised in subsequent publications, concluding the associated symptoms (45). The first line of treatment that the combination of the maximum flow rate of up to should be pelvic floor physical therapy with biofeedback 12mL/s with a detrusor pressure in excess of 25cm H2O (46). Conservative therapies are preferred in patients with represented cut-off parameters with the highest sensi- dysfunctional voiding related or secondary to sexual abuse, tivity and specificity (37). Video-urodynamic investiga- or in patients with history of depression or anxiety. Botu- tions allow to identify bladder outlet obstruction by ra- linum toxin injection into the external urethral sphincter is

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useful for various pelvic floor disorders, but there is very Post-operative Urinary Retention limited literature about cases with dysfunctional voiding. Sacral neuromodulation is described in some studies but Urinary retention is a recognized post-operative complica- its use remains limited (33). Pharmacotherapy to decrease tion in men and women. Several factors are involved in the urethral resistance has not been shown to be useful in this pathophysiology, including bladder over-distention, trau- condition, although there is a report suggesting promising matic instrumentation, reduced contractility of the bladder, results using Baclofen 10mg three times per day. Further increased outlet resistance, nociceptive inhibitory effect, studies are needed to confirm the reported findings of im- pharmaceutical influences, preexisting outlet pathology provement on number of voids and increase in maximum and decreased micturition reflex activity. Incontinence sur- flow rate (47). gery is a common cause of urinary retention and voiding dysfunction in women. The short-term retention rate ranges Primary Bladder Neck Obstruction between 0% and 27%, and the long-term rate between 0% and 3.8% (56). A too-tight tape or the bad contractility of Primary bladder obstruction was first described by Marion the bladder are the two most common causes. In patients in 1933 (48); in 1973 Turner-Warwick recommend the use of undergoing midurethral sling placement, urinary retention urodynamics and voiding cystourethrography to diagnose is less likely when using the transobturator versus the ret- this condition (49). Later on Diokno in 1984 described the ropubic approach (57). Risk factors include advanced age, condition in women (50) although the real cause remains presence of high post-void residual volume, use of Valsalva rather unclear. Among the possible suggested causes are effort to void during pre-operative urodynamic evaluation, morphologic etiology issues related to failure of dissolution previous incontinence surgery or prolapse surgery, and Qmax of mesenchymal tissue at the bladder neck, or inclusion <15mL/s (58). As it is difficult to predict which patients may of abnormal amounts of non-muscular connective tissue suffer from these problems, careful post-operative monitor- resulting in hypertrophy smooth muscle fiber contractures, ing is essential to identify patients who may need further and other inflammatory changes (51). In cases of primary intervention. The prolonged delay in treatment for those suf- bladder neck obstruction the bladder neck fails to prop- fering from post-operative voiding dysfunction may lead to erly open during voiding in the absence of any anatomic irreversible changes. A delayed de-obstructive surgery is obstruction. This condition has been identified as the un- associated with worse long-term outcomes compared to derlying cause of urinary obstruction in between 9% and early intervention (58). 16% of urodynamic studies (35, 52). Mean age of patients suffering from primary bladder neck obstruction has been Fowler’s Syndrome identified as 59.2 years, while voiding symptoms constitute the main patients’ complaints. The level of obstruction is Fowler’s syndrome is defined as an abnormality of the ex- localized on the bladder neck. Reported urodynamic find- ternal urethral sphincter in young post-menarcheal women ings include increase of EMG activity in 14% of cases and with polycystic ovaries (40% of association), high-volume a maximum flow rate of 9.74 mL/s, together with a Pde- painless retention and abnormal urethral sphincter EMG tQmax of 99.72cm H2O (53). Treatment depends on pa- (59). The precipitating event is apparently unconnected. tient’s status and associated conditions, relying on watch- All investigations are normal and the needle electromyo- ful waiting, pharmacotherapy or surgical intervention. If graphic signals are the gold standard for the diagnosis. No the patient has no evidence of upper or lower urinary tract drug treatment has proven to be useful for this condition; all damage, watchful waiting may be advisable. The choice opioid analgesic drugs would need to be stopped as these of pharmacotherapy relies on the use of α-antagonists as might worsen the problem. Self-catheterization is an option several studies have demonstrated their effectiveness (54). but is usually very poorly tolerated. To restore the normal If pharmacotherapy fails or in cases of complete urinary voiding the best current therapy is sacral neuromodulation retention, a transurethral incision of the bladder neck at 5 (60). The mechanism of action of sacral neuromodulation o’clock and/or 7 o’clock may be indicated (54). The incon- is not well known; nevertheless, it is thought to be related tinence rate after this procedure has been reported as low to the release of the detrusor from presumed inhibition that as 3% (55). emanates from the pathologic sphincter afferent activity (59).

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Disclaimers 14. Teoh YJ, Kan CF, Tsui B, Chiu PK, Man CY, Hou SS, et al. The authors have no proprietary interest with regard to this article. Ambulatory care programme for patients presenting with acute urinary retention secondary to benign prostatic hyper- Corresponding Author: plasia. Int Urol Nephrol. 2012;44:1593. David Castro-Diaz 15. Fitzpatrick JM, Desgrandchamps F, Adjali K, Gomez Guerra Department of Urology L, Hong SJ, El Khalid S, Ratana-Olarn K; Reten-World Study University Hospital of the Canary Islands, University of La Laguna. Group. Management of acute urinary retention: a worldwide Ofra s/n. 38320- La Cuesta- La Laguna survey of 6074 men with benign prostatic hyperplasia. BJU Santa Cruz de Tenerife - Spain International. 2012;109:88. [email protected] 16. Zeif HJ, Subramonian K. Alpha Blockers prior to removal of a catheter for acute urinary retention in adult men. Cochrane database of systematics reviews 2009 (4). References 17. 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Urinary Retention (UR) in women UR in women Prevalence and etiology

Additional Urinary retention in women Urethra fails to infravesical relax resistance is Conservative management • Acute Postsurgical or anaesthesia present UR • Chronic Neurologic, anatomic, C. Naranjo-‐Ortiz, PT, PhD inflammatory, functional and idiopathic Failure in the synchronization of Detrusor unable to contract detrusor • Unknown in general (both types) contraction and urethral relaxation PREVALENCE • Urodynamic reported 12% -‐17% WHY UR OCCURS?

Clinical evaluation of the Pelvic Floor Acute UR in women Chronic UR in women Muscles (PFM)

Urinary tract Reduced infection sensation Electrophysiology •Palpation •Perineal US Painful or painless •PFM strength •Superficial •Static Depends on Requires Urgency, •PFM coordination electromyography •Dynamic neurological Sudden onset catheterization incontinence Hesitancy PFM status •With or without flowmetry Ultrasound (US) PFM assessment Frequency, Strainingto imaging nocturia void

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Chronic UR in women Chronic UR in women PFMT – Relaxation techniques Conservative management Conservative management

PFM work synergistically PHYSIOTHERAPY OTHER AIDS with deep abdominal Coactivation between muscles, multifidi PFM and transverse PFMT Relaxation muscles and respiratory abdominis (TA) Behavioural treatment: diaphragm Recommended about In order to techniques Life-‐style changes three months of return to conservative management normal bladder function Clean intermittent self-‐ Bio feed-‐back catheterization Adherence is very important Electrostimulation

Behavioural treatment: Feedback and biofeedback Electrical Stimulation Life-‐style changes Stimulate afferent fibers to convey bladder filling sensation Active use of PFM is a key voiding skill Stimulate efferent Biofeedback Improve fibers to induce Biofeedback can micturition bladder Feedback is techniques: coordination be used for contraction Altering voiding habits,fluid essential in verbal, visual, autonomic intake and other aspects of life-‐ motor learning manometric, style functions EMG, US, etc. Behaviouraltreatmentare usually comprised of several components and tailored to the needs of the individual woman Relax PFM Re-‐educate and overactivity condition PFM

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Clean intermittent self-‐catheterization

Intermittent catheterization means regularly emptying of the bladder using a catheter that is removed after each use THANK YOU

Long-‐term use of hydrophilic www.fisioterapianaranjo.com catheters is reported to prevent urethral trauma and complications fi[email protected]

Several recent reports support the use of single-‐use hydrophilic catheters to reduce the risk of urologicalcomplications such as UTI and hematuria

3 Notes