Nonneurogenic female bladder outlet obstruction: Conservative and medical management.

INTRODUCTION: In nonneurogenic female bladder outlet obstruction (BOO), management goals include reduction of outlet resistance to increase urinary outflow and improve bladder voiding to prevent or reduce lower and upper urinary tract (LUT and UUT) function deterioration, by correcting the underlying etiology. As significant progress has been achieved in the conservative and pharmacological management of nonneurogenic female BOO, the purpose of this article is to review and summarize the current literature. MATERIALS AND METHODS: For this narrative review, a PubMed® search was performed by cross-referencing the keywords "female bladder outlet obstruction," "female voiding dysfunction," "conservative management," "pharmacological management," and "treatment" with various terms related to the management of female BOO. Clinical practice guidelines and landmark reviews from the most renowned experts in the field were also used. MANAGEMENT: This review discusses and summarizes the conservative and pharmacological management of nonneurogenic female BOO based on the most relevant data currently available in the literature. CONCLUSION: The recent advances in the understanding of underlying mechanisms involved in female BOO allow for more individualized management. Conservative and pharmacological options show interesting outcomes, particularly in the context of a functional cause of BOO. Overall, the level of evidence is still low regarding the use of conservative and pharmacological measures and more long-term data are required.

Outcomes of bladder neck botulinum toxin injection for female primary bladder neck obstruction-does subjective improvement correlate with an objective assessment?

INTRODUCTION AND HYPOTHESIS: Common options for management of primary bladder neck obstruction (PBNO) in women include medications and surgical treatment. Less invasive treatment such as bladder neck botulinum toxin injection can be an alternate therapy in patients with failed conservative management. In this study, we describe the subjective and objective outcomes, patient satisfaction, and willingness for repeat treatment with bladder neck botulinum toxin injection in females with PBNO. METHODS: A retrospective analysis of ten female PBNO patients managed with bladder neck botulinum toxin injection was performed. Subjective parameters were quantified with symptom assessment, International Prostate Symptom Score (IPSS), and Quality of life (QoL) score. Objective parameters were assessed with maximum flow rate (Qmax) in uroflowmetry and postvoid residual (PVR). RESULTS: The mean pre-treatment IPSS, QoL score, Qmax, PVR was 24.2 ± 5.0, 4.8 ± 0.63, 5.73 ± 3.18 ml/s, and 210 ± 66 ml, respectively. Seven of the ten patients subjectively improved (IPSS 12.9 ± 9.6, QoL2.9 ± 1.6, p < 0.05). Three patients improved objectively (mean Qmax 17.3 ± 2.7 ml/s, PVR 42.7 ± 7.5 ml, p < 0.05). Three patients accepted repeat botulinum toxin injection. Three patients who showed no improvement underwent bladder neck incision with resolution of symptoms. CONCLUSION: Botulinum toxin can be an intermediary therapy in female patients with PBNO who want a minimally invasive procedure.

Detrusor underactivity in women: A current understanding.

AIMS: To examine the current understanding and management of detrusor underactivity (DUA) and underactive bladder (UAB) in women. METHODS: A review of the current literature was performed with a specific focus on new management strategies and treatment options for women with DUA and UAB. RESULTS: DUA has become an area of increased interest in recent years. Affecting up to 45% of older women undergoing urodynamic evaluation for non-neurogenic lower urinary tract symptoms, DUA is common. There are a variety of possible etiologies including neurogenic or myogenic dysfunction. As there is currently no cure for DUA and no way to restore the ability of the detrusor muscle to contract, management of DUA in women is mostly focused on effective bladder drainage by urinary catheterization. Clean intermittent catheterization is the gold standard for bladder drainage however for a variety of reasons, women with DUA often are managed with indwelling urethral catheter or suprapubic tube. Medications, sacral neuromodulation, and the inFlow urinary prosthesis are also treatment alternatives or additions to catheterization. Novel therapies using stem cells and gene therapy are also under investigation for the treatment of DUA and UAB. CONCLUSIONS: DUA is likely more prevalent than recognized and undertreated in women. It is vital that further research in treatment options beyond catheterization be developed for these patients to offer patients a variety of treatment options.

Management of Postoperative Lower Urinary Tract Symptoms (LUTS) After Pelvic Organ Prolapse (POP) Repair.

PURPOSE OF REVIEW: Pelvic organ prolapse (POP) is a common condition for which approximately 200,000 US women annually undergo surgical repair [Am J Obstet Gynecol 188:108-115, 2003]. After surgical correction, persistent or new lower urinary tract symptoms (LUTS) can be present. We provide guidance on the current tools to predict, counsel, and subsequently handle postoperative LUTS. The current literature is reviewed regarding LUTS diagnosis and management in the setting of prolapse surgery with an emphasis on newer developments in this area. RECENT FINDINGS: 1. More severe stages of prolapse are positively correlated with obstructive symptoms [Am J Obstet Gynecol 185:1332-1337, 2001], but not with other LUTS [Adv Urol 2013:5673753, 2013, Eur J Obstet Gynecol Reprod Biol 177:141-145, 2014, Am J Obstet Gynecol 199:683, 2008, Int Urogynecol J 21:1143-1149, 2010]. 2. One-week ambulatory pessary trial is an effective way to approximate postoperative results-one study correctly predicted persistent urgency and frequency in addition to occult stress urinary incontinence in 20% of study population [Obstet Gynecol Int 2012:392027, 2012]. 3. No preoperative overactive bladder (OAB) symptom was the best predictor for the absence of de novo OAB symptoms postoperatively [Int Urogynecol J 21:1143-1149, 2010]. 4. Urge incontinence patients respond favorably to sacral neuromodulation [Neurourol Urodyn 26: 29-35, 2007], botulinum toxin, and anticholinergic therapy [Res Rep Urol 8:113-122, 2016 , N Engl J Med, 367:1803-1813, 2012]. 5. Primary bladder outlet obstruction (BOO) can be treated effectively with alpha antagonists or anticholinergics, timed voiding, and pelvic physiotherapy as first-line therapy. Counseling regarding postoperative LUTS is key when planning POP surgery. A thorough understanding of patient history is crucial to successful repair. Patients with significant preoperative symptoms, history of neurologic disease, pelvic floor dysfunction, bladder neck obstruction, or higher stages of anterior wall prolapse may be higher risk for postoperative LUTS. UDS with or without reduction and an ambulatory pessary trial can help prognosticate. Patients will likely maintain a positive therapeutic relationship postoperatively for LUTS if counseled preoperatively.

Trans-abdominal ultrasound shear wave elastographyfor quantitative assessment of female bladder neck elasticity.

INTRODUCTION AND HYPOTHESIS: Disorders of micturition result from a wide variety of conditions and evaluation often involves multiple diagnostic modalities. However, the sensitivity and specificity of these techniques are highly variable and may not always yield a diagnosis. Novel imaging techniques such as ultrasound shear wave elastography may help to improve diagnostic accuracy. METHODS: Continent women were recruited from outpatient gynecology offices from a tertiary medical system. Participants underwent ultrasound evaluation with measurement of the shear wave velocity (SWV) of the bladder neck (BN). SWV was used to determine the Young's modulus of the bladder neck. The median bladder neck stiffness was calculated and univariate and step-wise and backward multivariate logistic regression analyses were used to identify significant patient characteristics associated with bladder neck stiffness above or below the median. RESULTS: Fifty-seven women underwent SWE of the bladder; 12 were excluded, and 45 were included in the analysis. The median bladder neck stiffness of the study population was 22 (17.1-28.2) kPa. Age greater than 45 years was associated with a bladder neck stiffness above the median, OR 8.39, p < 0.001. Having no vaginal deliveries was also associated with a bladder neck stiffness greater than 22 kPa, unadjusted OR 4.76 (95 % CI 1.41-20.0, p = 0.012). Bladder volume and bladder neck thickness were not significantly associated with bladder neck stiffness above or below the median. CONCLUSION: Trans-abdominal shear wave elastography can be used to quantitatively assess bladder neck stiffness. This technique may potentially be useful for evaluating chronic urinary retention.

The inFlow intraurethral valve-pump for women with detrusor underactivity: A summary of peer-reviewed literature.

Context: Detrusor underactivity (DUA) in women can result in urinary retention and the need for chronic bladder drainage management. Without a cure for urinary retention due to DUA, treatment options are focused on effective bladder drainage most often by intermittent or continuous catheter drainage. The inFlow intraurethral valve pump was FDA approved for use in women with this condition in 2014.Methods: Using a literature search, this clinical review sought to explore the epidemiology and commonly used treatment options for women with DUA and critically examine all available studies of the inFlow urinary prosthesis.Results: Due to a lack of effective treatments to improve detrusor function, DUA is generally considered incurable and there are limited treatment options which mostly focus on effective bladder drainage. The inFlow urinary prosthesis is a unique technology which utilizes a nonsurgically inserted urethral device for females to assist with bladder drainage due to DUA. The inFlow urinary prosthesis has been used in Europe and elsewhere for 20 years and is the subject of seven peer-reviewed clinical studies. For those that tolerate the device (about half), the inFlow urinary prosthesis has a low infection rate and side effect profile, is easy to use, and can normalize urination by returning autonomy to patients and thus improve their quality of life.Conclusion: There is no cure for women with DUA. Bladder drainage can be managed by intermittent or continuous catheterization. Appropriately selected women interested in an alternative to catheterization may be offered an on-device trial of the inFlow urinary prosthesis.

Surgical Management of Female Voiding Dysfunction.

Surgical intervention for female voiding dysfunction is common, involving a single or multifaceted approach affecting multiple organ systems in the pelvis. Surgical success relies on knowledge of surgical history, anatomic approaches, and judicious use of supports or materials. Owing to the varied repairs used over the last few decades, it is important for the general surgeon to understand both current and historic approaches. This understanding will help in planning future pelvic surgery as well as in evaluating current ramifications of prior surgery.

Current opinion of the treatment of female voiding dysfunction / 대한산부인과학회지

The incidence of female voiding dysfunction is increasing nowadays and is getting more of attention with the aging society. Various treatment methods have been applied to treat stress urinary incontinence, overactive bladder, and voiding difficulty. However, surgery for stress urinary incontinence, medication and bladder training for overactive bladder, and intermittent self-catheterization to treat voiding difficulty remain as the mainstay of management. These standard methods cannot be applied to all patients, and does not always lead to successful outcomes, suggesting that we should acquire the correct knowledge in possible ways to treat these patients. In this review, we will focus on the treatment effects of conservative, medical, and surgical treatment which are currently available, based on the evidence of literatures, and address the promising therapeutic modalities such as new minimally invasive surgical procedures for stress urinary incontinence, botulinum toxin A injection, electrical stimulation (sacral neuromodulation, posterior tibial nerve stimulation), radiofrequency therapy, new pharmacologic agents for overactive bladder and voiding difficulty.

Current opinion of the treatment of female voiding dysfunction / 대한산부인과학회지

The incidence of female voiding dysfunction is increasing nowadays and is getting more of attention with the aging society. Various treatment methods have been applied to treat stress urinary incontinence, overactive bladder, and voiding difficulty. However, surgery for stress urinary incontinence, medication and bladder training for overactive bladder, and intermittent self-catheterization to treat voiding difficulty remain as the mainstay of management. These standard methods cannot be applied to all patients, and does not always lead to successful outcomes, suggesting that we should acquire the correct knowledge in possible ways to treat these patients. In this review, we will focus on the treatment effects of conservative, medical, and surgical treatment which are currently available, based on the evidence of literatures, and address the promising therapeutic modalities such as new minimally invasive surgical procedures for stress urinary incontinence, botulinum toxin A injection, electrical stimulation (sacral neuromodulation, posterior tibial nerve stimulation), radiofrequency therapy, new pharmacologic agents for overactive bladder and voiding difficulty.