The session discusses the evidence on female bladder obstruction management, detrusor inactivity and detrusor overactivity.
The pelvic floor muscle relaxation training results in significant reductions in vaginal resting pressure and surface EMG activity. The evidence coming from studies on pediatric populations further supports the recommended action of offering pelvic floor muscle relaxation training for the treatment of female bladder outlet obstruction. A systematic review has shown a significant improvement in the symptoms of bladder obstruction with the use of alpha blockers. The urodynamic changes were similar as compared to placebo. The results from a randomized controlled trial have demonstrated that oral baclofen, a muscle relaxant, is better than placebo in improving maximum flow rate PdetQmax among females with increased EMG activity during voiding. A systematic review based on a case series on dysfunctional voiders has shown that botulinum toxin injection has 86-100% success rates in improving symptoms, reducing residual volume and reducing voiding the chooser pressures. While there is abundant evidence on sacral nerve stimulation for bladder outlet obstruction, there are no comparative trials to study its effect on female bladder outlet obstruction alone. been identified. A case series on 60 women with functional bladder outlet obstruction has shown a 72% spontaneous voiding rate and a reduced frequency of catheterization. The evidence on the effect of urethral dilatation of up to French 35-41 includes a systematic review of three randomized controlled trials on women with strictures; it shows a mean success rate of 49%, with higher rates found among treatment naive patients. The results from a comparative study showed that programmed intermittent dilatation had better outcomes than on-demand dilatation. Another systematic review showed that after a follow-up of 12 months, repeat intervention may be required. There may also be worsening and development of stress urinary incontinence post dilatation. Among women with strictures, the panel recommends offering internal urethra to meet with post-operative dilatation. Women must be advised on the limited long-term improvement and the risk of postoperative stress. Bladder neck insertion or resection for primary bladder neck outlet obstruction has been reviewed in several case series. They show a success rate between 76-100%. A case series review on the effectiveness of urethroplasty for female strictures using vaginal/ labial flaps, vaginal/labial grafts and oral mucosal grafts had success rates of over 80% and a recurrence rate of 23%. The EAU guidelines on Urethral Stricture recommend urethral dilatation as the first management option and urethroplasty for recurrent strictures in those fit. For procedures of bladder outlet obstruction, especially after urethrolysis or sling incision or resection, have a good success rate in improvement of symptoms. The recurrence of urinary incontinence is 23%, with delayed surgical release associated with lower incontinence recurrence. To conclude, in summary, the science on bladder female bladder outlet obstruction is still evolving and there is a need for better study designs which should have a well-defined female population diagnosed with bladder obstruction using appropriate criteria.
An underactive bladder (UAB), a clinical syndrome based on clinical symptoms and detrusor underactivity (DU) is more of a functional concept. There are different sites of dysfunction with very precise mechanisms. With respect to diagnostics, there are no pivotal symptoms. It is important to rely on urodynamic studies such as uroflowmetry, PVR volume measure and bladder volume efficiency to identify women with DU. However, there may be considerable overlap in findings with bladder obstruction and it may be important to rely on invasive urodynamics with pressure flow studies. In such cases, the cut of values of Qmax and PdetQmax can be considered. Despite having many diagnostic options, there is no ideal method for measuring detrusor contraction function. For management of detrusor contraction, in conservative management, the level of evidence is not very high for abdominal straining with relaxation and there is a risk of prolapse. The patients can be encouraged for double voiding, but the evidence for this is weak. The use of clean intermittent self-catheterization is standard treatment for those who cannot empty their bladder (strong recommendation). Indwelling transurethral catheterization or suprapubic cystostomy can be suggested (weak recommendation). Among pharmacological therapy, the recommendation is to NOT routinely recommend parasympathomimetics for management of UAB due to lack of efficacy and adverse events. Alpha blockers or intravesical prostaglandins can be advised; however they carry a weak recommendation. With respect to surgical treatment, there is a high level of evidence for sacral nerve stimulation as it improves voided volume and decreases PVR volume. The level of recommendation for on a botulinum toxin A is not high but may improve symptoms in patients. Detrusor myoblasty should not be routinely suggested. In conclusion, most therapeutic interventions have low levels of evidence and clean intermittent self-catheterization remains to be the gold standard of treatment.
Detrusor obstruction (DO) is defined as a urodynamic observation characterized by involuntary contractions during the filling phase, which may be spontaneous or provoked. There are different kinds of DO- phasic DO, terminal DO and DO incontinence. Overactive bladder (OAB) symptom based definition with exclusion of obvious pathologies, and this. The definition precludes the need for invasive urodynamic studies in order to start behavioral therapy and pharmacological therapy. The role of DO in the pathophysiology and management of OAB is debatable. DO is seen in 54% patients with OAB; it is seen in 44% women with OAB-dry and 58% women with OAB-wet. The relation of DO with urgency is interesting as patient-reported sensation of urinary urgency is not always due to concomitant DO. DO is not specific for overactive bladder, since it can also be found in asymptomatic women. But, the rates of DO are higher in patients with OAB as compared to those without. The patient characteristics associated with DO with OAB are older age, having smaller maximum, more rigid volumes, having more incontinence episodes and more likely reports of early strong desire and urgency. Women with DO experience more significantly impaired quality of life and a greater degree of bladder dysfunction. Despite these differences, the diagnosis of DO has no predictive value for treatment response in studies on antimuscarinic agents, on a botulinum toxin A, sacral nerve stimulation in patients with OAB. As a result, the EAU guidelines state the highest level of evidence that
urodynamic diagnosis of DO does not influence treatment outcomes in patients with OAB. In conclusion, DO is found in approximately half of OAB patients and may be found in patients without urinary symptoms. DO is not associated with the severity of OAB symptoms, impairment of quality of life and aging.
European Association of Urology (EAU) Annual Congress 2023, 10th March - 13th March 2023, Milan, Italy
