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Pelvic Retention in Urology

The role of the IPSS (International Prostate Symptoms Score) in predicting acute retention of urine in patients undergoing major joint arthroplasty.

Elkhodair S, Parmar HV, Vanwaeyenbergh J
Surgeon. 2005 Apr;3(2):63-5.

BACKGROUND: Acute urinary retention following major joint arthroplasty is common. It does necessitate instrumentation, puts patients at risk of complications, and causes discomfort and embarrassment. The aim of the study was to find a test to help the surgeon to predict the possibility of acute retention of urine. METHODS: Male patients admitted for elective major joint arthroplasty filled in an IPSS (International Prostate Symptoms Score) during the pre-operative visit. They were observed post-operatively to document if they passed urine spontaneously or went into acute retention. RESULTS: There was a strong correlation between the IPSS and the likelihood of developing acute retention. Patients with moderate to high IPSS had a 55% to 100% chance of developing acute retention of urine, respectively. CONCLUSION: The IPSS proved to be a simple and reliable test to help the surgeon in predicting the possibility of developing acute retention. It might be a good addition to the pre-admission clinic investigations in patients undergoing major surgery. It could consolidate the decision to pre-emptive catheterisation in patients at risk.

Intermittent catheterisation in older people: a valuable alternative to an indwelling catheter?
Pilloni S, Krhut J, Mair D, Madersbacher H, Kessler TM
Age Ageing. 2005 Jan;34(1):57-60. Epub 2004 Nov 10.

OBJECTIVES: To investigate whether intermittent catheterisation is a valuable alternative to an indwelling catheter in patients older than 70 years with post-void residuals more than 50% of the bladder capacity. PATIENTS AND METHODS: We retrospectively reviewed the medical records of 21 patients (14 women, 7 men) older than 70 years in whom intermittent catheterisation was initiated because of voiding dysfunction with post-void residuals more than 50% of the bladder capacity resistant to other treatment. Twelve patients mastered the technique of intermittent self-catheterisation, seven were catheterised by their partners and two by nurses. RESULTS: The mean age of patients was 76.5 years (range 71-83 years) and the mean observation period with regard to intermittent catheterisation was 27.9 months (range 5-129 months). For those relying on intermittent catheterisation, the urinary tract infection rate was 0.84 per year and patient (range 0-3), and urinary continence was restored in all of the six previously incontinent patients. Eighteen of the 21 patients reported a significantly improved quality of life owing to the restoration of urinary continence, decreasing of daytime frequency, nocturia and urge, and the lowering of the urinary tract infection rate. CONCLUSIONS: Intermittent (self-) catheterisation is a safe and valuable technique in older people with significant post-void residuals owing to detrusor underactivity. Urinary continence is restored, urge, daytime frequency and nocturia are decreased, and the urinary tract infection rate is diminished, resulting in improved quality of life. Therefore, intermittent (self-) catheterisation is strongly recommended in older people.

Chronic urinary retention and pelvic floor hypertonicity after surgery for endometriosis: a case series.
Gehrich AP, Aseff JN, Iglesia CB, Fischer JR, Buller JL
Am J Obstet Gynecol 2005 Dec;193(6):2133-7.

OBJECTIVE: The purpose of this study was to evaluate 4 cases of chronic urinary retention and pelvic floor muscle spasms after surgery for endometriosis. STUDY DESIGN: These patients underwent a complete history, physical exam, and diagnostic work- up. The results were analyzed with regards to type and extent of inciting surgery, diagnostic findings, postoperative recovery, and treatment success. RESULTS: The patients' mean age was 39.5 years and all had undergone various surgical interventions for endometriosis. In addition to urinary retention, all developed debilitating pelvic floor muscle spasm postoperatively. Physical exam revealed pelvic floor hypertonicity and urodynamics indicated hypoactive detrusor contractility. Neurodiagnostic testing gave evidence of neuropathy in all subjects. CONCLUSION: Extensive endometriosis surgery may pose a risk for postoperative bladder dysfunction and pelvic floor muscle spasm.

Obstruction after Burch colposuspension: a return to retropubic urethrolysis.
Anger JT, Amundsen CL, Webster GD
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 10;:1-5.

We compare our postoperative outcomes of a vaginal vs abdominal urethrolysis after an obstructed Burch colposuspension. We performed a retrospective review of all women who had undergone a Burch urethrolysis from 1997 through 2003. Data collected included pelvic examination, cystoscopic and urodynamic findings, surgical morbidity, and pre- and postoperative urogynecologic symptomatology. Sixteen women underwent Burch urethrolysis. Preoperative symptoms were obstructive in 6, overactive in 2, and both (obstructive/overactive) in 8. All had an acute retropubic angulation of the urethral axis as well as a retropexed urethra that prohibited sagittal rotation of a rigid cystoscope. Seventy-eight percent of the women with urodynamic information met urodynamic criteria for urethral obstruction. Average follow-up was 7 months, and of those undergoing a vaginal urethrolysis, three out of seven (43%) had resolution of their obstructive or overactive symptoms postoperatively. In contrast, seven out of nine women (78%) who underwent a retropubic urethrolysis had relief of their obstructive or overactive bladder symptoms. In our cohort study, an abdominal retropubic urethrolysis was more successful in relieving urethral obstruction than a vaginal urethrolysis.

Female voiding dysfunction.
Olujide LO, O'sullivan SM
Best Pract Res Clin Obstet Gynaecol 2005 Sep 9;.

Female voiding dysfunction is poorly understood; it lacks standard definitions, and there is no consensus on diagnostic criteria. In the majority of women who are neurologically intact the cause is idiopathic. It affects the sufferers' quality of life, but unfortunately there is a paucity of published literature on its management. This review examines the current knowledge on the management of this common problem. Diagnosis is aimed at identifying the underlying aetiological factors, which are discussed, as well as the importance of a detailed history and focused physical examination. Investigations essential to management are outlined. Developments in the medical treatment of voiding dysfunction have been disappointing. The role of surgery is even more limited except for those with postoperative voiding problems after new-generation sling procedures. Intermittent self-catheterisation, supervised and supported by a dedicated nursing specialist, remains the mainstay of management. A multidisciplinary approach is essential to success. Emerging treatment modalities such as sacral and peripheral neuromodulation and the use of alpha(1)-blockers are discussed. Botulinum toxin A injections have been useful in some cases. There are relatively few publications on the effectiveness of these interventions in clinical practice. These issues need to be addressed by quality research. Female voiding dysfunction presents a challenge to urogynaecologists and urologists alike.

Urinary retention in a general rehabilitation unit: prevalence, clinical outcome, and the role of screening.
Wu J, Baguley IJ
Arch Phys Med Rehabil 2005 Sep;86(9):1772-7.

OBJECTIVE: To document the prevalence of, risk factors for, and outcomes of, urinary retention (UR). DESIGN: Prospective observational study. SETTING: A subacute general (predominantly geriatric) rehabilitation unit. PARTICIPANTS: Three hundred nineteen consecutive patients (196 women, 123 men). INTERVENTIONS: Twenty-two patients were catheterized for acute UR in the acute facility prior to transfer to rehabilitation. Patients admitted without catheters (n=297) had their postvoid residual (PVR) volumes assessed via a bladder scanner within 72 hours of admission. MAIN OUTCOME MEASURE: PVR volumes of 150 mL or more were considered abnormal. RESULTS: PVR volumes in the 297 "asymptomatic" patients were 150 mL or more in 64 (21.5%) patients. The risk of UR was greatest among male patients who had lower admission FIM instrument scores, neurologic disorders (eg, stroke or multiple sclerosis), cognitive impairment, urinary incontinence, a history of previous prostate, bladder, or voiding problems, were taking anticholinergic medications, or were immobile. Patients with UR were significantly more likely to have a urinary tract infection at admission, have urinary incontinence on discharge, and to be discharged with referrals for community services for personal care or to residential care. Although patients with UR on admission had a lower discharge FIM score, they generally showed a greater degree of improvement in their FIM scores during their stay. CONCLUSIONS: Clinically unsuspected UR is common in patients admitted to a general rehabilitation unit. We recommend that all patients be screened for PVR on admission as an aid in bladder management.

Pelvic floor dysfunction after Burch colposuspension--a comprehensive study. Part I.

Kjolhede P, Wahlstrom J, Wingren G
Acta Obstet Gynecol Scand 2005 Sep;84(9):894-901.

OBJECTIVE: To evaluate the occurrence of voiding dysfunction and symptoms of genital prolapse at long-term follow-up after Burch colposuspension (Bc) in relation to the occurrence of the symptoms in an age-matched normal population. MATERIALS AND METHODS: A follow-up study of the 190 patients who underwent Bc in 1980-88 and 305 age-matched control women randomly selected from the general population. The participants answered a questionnaire in 1998 with detailed questions about the pelvic floor function. Univariate and multivariate analyses were performed. RESULTS: The prevalence and frequency of urinary incontinence were significantly higher in the patient group compared with those in the control group as were urge incontinence, difficulty to start voiding, time needed at the toilet for voiding, the need to return to the toilet for emptying the bladder, feeling of incomplete emptying of the bladder, and limitation of social life because of the leakage. The symptoms of genital prolapse were significantly more common in the patient group in spite of a significantly larger proportion of genital prolapse surgery in this group. Parity, high body mass index, heavy lifting work, chronic pulmonary diseases, hiatus hernias, and hysterectomy were significantly more common in the patient group than among the controls. CONCLUSIONS: At long-term follow-up, patients exhibit substantial symptoms of pelvic floor dysfunction (PFD) concerning voiding dysfunction and symptoms of genital prolapse compared with a normal population. This highlights the importance and need of treating pelvic floor disorders in a comprehensive way. Scientific works with comprehensive studies of PFD are needed.

Voiding dysfunction after tension-free vaginal tape: a conservative approach is often successful.
Mishra VC, Mishra N, Karim OM, Motiwala HG
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):210-4; discussion 214. Epub 2004 Sep 14.

The published literature has focused mainly on the efficacy of tension-free vaginal tape (TVT) in correcting stress incontinence with few reports of complications. We report our experience with the first 52 cases of TVT, specifically assessing voiding dysfunction after the procedure. We carried out a retrospective study of patients undergoing TVT surgery for stress urinary incontinence (SUI) between April 2001 and July 2003. Data were collected on period of catheterization, voiding and storage symptoms, their duration and management. Fifty-two women with a mean age 54 years (36-77) were included. Postoperatively, the urethral catheter was removed routinely within 12 h. Twelve patients (23%) failed to void spontaneously and needed recatheterization. Ten of them (83%) were able to resume spontaneous voiding within 3 months. Twenty patients (38%) complained of storage symptoms postoperatively. Sixteen (80%) responded to conservative treatment. Transient urinary symptoms after TVT sling for SUI are common but can usually be managed conservatively.

Effect of strip length on the contractile dysfunction of bladder smooth muscle after partial outlet obstruction.
Levin RM, Reed TP, Whitbeck C, Chichester P, Damaser M
Urology 2005 Sep;66(3):659-64.

OBJECTIVES: Partial outlet obstruction mediates decreased contractile responses and increased collagen synthesis; however, it is not known to what extent the increased collagen contributes to contractile dysfunction. METHODS: Sixteen WNZ rabbits were divided into three groups: control, 2-week obstructed, and 2-week sham. Each rabbit was anesthetized, and the bladder was excised and cut into equal width strips of 0.5, 1.0, and 2.0-cm lengths. The contractile responses to field stimulation, carbachol, potassium chloride, and adenosine triphosphate were determined. At the end of the experiment, each strip was fixed in formalin and immunostained for collagen. RESULTS: The contractile responses for the control and sham strips were similar for all strip lengths. In obstructed tissue, the shorter strip lengths generated significantly more tension per cross-sectional area than did the longer strips. The collagen density and distribution were similar for the control and sham bladders. The obstructed bladders had significantly increased collagen deposits between and within the smooth muscle bundles and cells. CONCLUSIONS: Because the relationship between strip size and contraction were similar for field stimulation, carbachol, and potassium chloride, it is the increased density of connective tissue within and between the muscle bundles and fibers that interferes with contraction (ie, the greater the strip length, the greater the interference and the greater the contractile dysfunction). Therefore, both functional and structural alterations in the obstructed bladder participate in contractile dysfunction.

Posterior tibial nerve stimulation in the treatment of voiding dysfunction: urodynamic data.
Wein AJ
J Urol 2005 Sep;174(3):1008.

Long-term results of sacral neuromodulation for women with urinary retention.
Wein AJ
J Urol 2005 Sep;174(3):1008.

Can alpha-blocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A prospective study.
Yucel S, Akkaya E, Guntekin E, Kukul E, Akman S, Melikoglu M, Baykara M
J Urol 2005 Oct;174(4 Pt 2):1612-5.

PURPOSE: Traditional treatment of dysfunctional voiding in children with urinary retention involves retraining the pelvic floor muscles using biofeedback. Alpha-blockers are reported to also be effective in children with urinary retention and dysfunctional voiding. We compared the efficacy of biofeedback and alpha-blockers for dysfunctional voiding and urinary retention in terms of residual urine volume and urge incontinence episodes, mean flow rates and urinary tract infections. MATERIALS AND METHODS: A total of 28 patients with a mean age of 6.25 years (range 4 to 10) presented with symptoms of urinary incontinence, urgency and urinary tract infections without anatomic and neurogenic causes of urinary retention. All patients had increased post-void residual (PVR) urine volume (mean 59 ml, 32% of age expected capacity [AEC]). The biofeedback group consisted of 16 children (mean age 6.5 years) and the alpha-blocker group consisted of 12 children (mean age 5.9 years). Both groups were also on continued timed voiding, constipation treatment and anticholinergics, which had been used for at least the last 6 months. Biofeedback (median 10, range 6 to 16 sessions) and doxazosin (0.5 to 2 mg) were administered. At 3 and 6 months incontinence episodes, urinary tract infections, mean urinary flow rates, PVR and parental satisfaction grades (1 to 10) were reevaluated. Six refractory cases were started on alpha-blockers and biofeedback, and reevaluated after 1 month and 3 months. RESULTS: Pretreatment mean PVR was 54 ml (30% of AEC), and mean posttreatment PVR was 21 ml (12% of AEC) and 9 ml (5% of AEC) at 3 and 6 months in the biofeedback group (p <0.05). Pretreatment mean PVR was 64 ml (38% of AEC), and posttreatment mean PVR was 17 ml (12% of AEC) and 13 ml (8% of AEC) at 3 and 6 months in the alpha-blocker group (p <0.05). There was no statistical difference in posttreatment PVR between the 2 groups (p >0.05). High PVR persisted in 4 (25%) biofeedback cases and in 2 (16%) alpha-blocker cases. Complete improvement in urge incontinence episodes occurred in 10 (62.5%) and 7 (70%) children in the biofeedback and alpha-blocker groups, respectively. In therapy responsive children parental satisfaction was higher with alpha-blocker than with biofeedback (9.2 vs 7.9, p <0.05). Refractory high PVR decreased significantly after combination treatment with biofeedback and alpha-blocker in 5 of 6 children (mean 80 ml, 35% of AEC vs mean 15 ml, 7% of AEC). No drug related side effect was reported in the alpha-blocker group. CONCLUSIONS: Alpha-blocker therapy seems to be a viable alternative to biofeedback in dysfunctional voiding in children with urinary retention to improve bladder emptying. Combination treatment (biofeedback and alpha-blockers) can be used as additional therapy in refractory cases.

Postpartum urinary retention.
Yip SK, Sahota D, Pang MW, Day L
Obstet Gynecol 2005 Sep;106(3):602-6.

Tape mobilization for urinary retention after tension-free vaginal tape procedures.
Nguyen JN
Urology 2005 Sep;66(3):523-6.

OBJECTIVES: To evaluate the efficacy of transvaginal tape mobilization as a method of treating urinary retention after tension-free vaginal tape (TVT) procedures, and secondly to evaluate the time to resumption of voiding function after TVT procedures. METHODS: Postoperative voiding function and the 1-year continence status of 163 consecutive women with stress incontinence treated with TVT procedures during a 35-month period were retrospectively analyzed. RESULTS: Of the 163 women, 63 underwent TVT placement alone and 100 underwent TVT with surgery for pelvic relaxation. Of the 163 women, 153 (94%) were able to void immediately without intervention. Of the voiders, those who underwent TVT alone voided adequately by 33 hours, and those who underwent TVT concurrently with surgery for pelvic relaxation voided adequately by 74 hours. Ten (6%) of the 163 women were unable to void after TVT placement and underwent transvaginal tape mobilization between postoperative days 3 and 10. All women voided spontaneously and suprapubic catheterization was discontinued within 37 hours and 48 hours of tape mobilization, respectively. Continence status and quality-of-life scores of the nonvoiders had improved significantly and did not differ from those of voiders at 1 year after surgery. CONCLUSIONS: Transvaginal tape mobilization is a simple and effective method of treating urinary retention after TVT placement and may be considered if voiding has not resumed by postoperative day 3.

Endoscopic treatment of multiple prostatic calculi causing urinary retention.

Bedir S, Kilciler M, Akay O, Erdemir F, Avci A, Ozgok Y
Int J Urol 2005 Jul;12(7):693-5.

Although prostatic calculi are relatively common, the etiology of these stones is not clear. We report a case with multiple prostatic calculi causing urinary obstruction and a concomitant bladder stone. We treated these stones endoscopically. We found a lot of different sized stones endoscopically, some protruding into the urethra, some filling different cavities on the prostate. So these cavities suggest prostatic calculi may occur related to intraprostatic reflux in the congenital or acquired diverticulum of the prostatic tissue. In addition, the stone composition of the bladder and prostatic stones was the same. All of these results show that the origin of bladder and prostatic stones can be the same. This case also supports a theory of intraprostatic reflux and urine stasis.

Paraurethral leiomyoma in a female causing urinary obstruction.
Bruschini H, Truzzi JC, Simonetti R, Mesquita R, Delcelo R, Szenfeld J, Srougi M
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 18;.

We report a case of paraurethral leiomyoma in a female patient, in which the first symptoms were dysuria and sensation of incomplete voiding. The physical examination revealed a mass in the anterior vaginal wall. The diagnosis was made through ultrasonography and pelvic MRI and confirmed by transvaginal ultrasound-guided needle biopsy. The surgical excision was accomplished without opening the urinary tract. A review of the relevant published studies and a suggestion for the appropriate management of these cases are included.

Multi-Centre Study of Intraurethral Valve-Pump Catheter in Women with a Hypocontractile or Acontractile Bladder.
Chen TY, Ponsot Y, Carmel M, Bouffard N, Kennelly MJ, Tu LM
Eur Urol 2005 Jun 15;.

OBJECTIVES: To compare the safety, effectiveness and patient satisfaction of an intraurethral valve-pump catheter (In-Flowtrade mark) versus the current standard of care, clean intermittent catheterization (CIC), for females with hypocontractile or acontractile bladder. MATERIALS AND METHODS: The study was a multi-centre, prospective, single-arm crossover study. Eligible patients underwent a 1-week In-Flow tolerability trial. Successful patients then continued through an 8-week baseline phase using CIC, followed by a 16-week In-Flow treatment phase, and a final 4-week treatment withdrawal phase. Outcome measures included post-void residual (PVR), Wagner incontinence-specific quality of life (I-QOL), rate of urinary tract infection and adverse events. At study completion, open enrolment was offered. RESULTS: A total of 273 women with a mean age of 48.9 years using CIC entered the study in 18 centres under either the original (n=88) or revised protocols (n=185). The revised protocol included the addition of a 1-week tolerability trial. The reasons for the large early withdrawal of subjects (169/273) were mainly related to initial discomfort and leakage. A total of 77 patients completed the In-Flow treatment phase. PVR was comparable during baseline CIC phase and In-Flow treatment phase (20.3ml vs. 16.1ml), with significantly improved quality of life (QOL; mean improvement of I-QOL score +25.9; p<0.001). CONCLUSION: The In-Flow catheter appears to be a viable alternative to CIC. A subgroup of patients, mainly those unsatisfied with the currently available treatments, was more likely to tolerate In-Flow catheters, and they may achieve enhanced independence and QOL.

Do Prostatic Infarction, Prostatic Inflammation and Prostate Morphology Play a Role in Acute Urinary Retention?
Tuncel A, Uzun B, Eruyar T, Karabulut E, Seckin S, Atan A
Eur Urol 2005 Jun 15;.

OBJECTIVE: To investigate whether there is a role of prostatic infarction, prostatic inflammation and prostate morphology in acute urinary retention (AUR) etiology. METHODS: Ninety-eight consecutive male patients who were admitted to our clinic with either AUR or lower urinary tract symptoms (LUTS) were involved in the study. Patient age ranged from 43 to 88 years (median age 70). Group 1 consisted of 53 (54%) patients with AUR, and Group 2 consisted of 45 (46%) patients with LUTS. In Group 1 and Group 2, 58.4% (n:31) and 62.2% (n:28) of the patients underwent transurethral prostate resection, 41.6% (n:22) and 37.8% (n:17) of the patients underwent suprapubic transvesical prostatectomy, respectively. Each patient was asked about the factors: smoking habits, taking previous general anesthesia and preexisting cardiovascular disease such as hypertention and atherosclerotic coronary vascular disease which may lead to AUR via prostatic infarct. Prostatic infarction, prostatic inflammation and prostatic morphology were examined in the patients' specimen. RESULTS: Mean age, median serum prostate-specific antigen (PSA) level, and prostatic inflammation ratio were significantly higher in Group 1. There were not significant differences between the groups regarding prostate volume, prostatic infarction ratio and a type of prostatic morphology. In the present study, except for taking previous general anesthesia and preexisting cardiovascular disease, only prostatic inflammation was found important contributory factor on AUR. AUR risk was 3.03 times higher in the patients with prostatic inflammation (95%CI 1.28-7.15) (p=0.01). CONCLUSIONS: No significant effect of prostatic infarction was found on occurence of AUR which was more frequent in elderly patients. Prostatic inflammation may have an important risk factor in AUR etiology. Additionally, serum PSA levels were higher in AUR group. No association was found between a type of prostatic morphology and AUR.

Do subjective symptoms of obstructive voiding correlate with post-void residual urine volume in women?

Al-Shahrani M, Lovatsis D. Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan-Feb;16(1):12-4; discussion 14. Epub 2004 Jul 29.

The objective was to determine if symptoms of obstructive voiding correlate with post-void residual urine volume measured by catheterization. A cross-sectional study of 134 consecutive women referred to a tertiary urogynecology clinic was performed. Subjects were interviewed regarding three types of obstructive voiding symptoms: a sensation of incomplete emptying, straining to void, and slow urine stream. Post-void residual urine volume was measured by catheterization as the gold standard. Data for each symptom were analyzed using Cohen's kappa test, sensitivity, specificity, likelihood ratios for a positive of negative test, and positive and negative predictive values. A total of 11 out of 134 patients (8%) had a post-void residual volume greater than 100 ml. Of these 11, 1 had symptoms of incomplete emptying (9%), 1 had symptoms of straining to void (9%), and 2 had symptoms of slow urine stream (18%). Sensitivity, specificity, likelihood ratio for a positive symptom, likelihood ratio for a negative symptom, positive predictive value, negative predictive value, and Cohen's kappa, respectively, were 9%, 80%, 0.47, 1.13, 4%, 91%, and 0.05 for the symptom of incomplete emptying, 9%, 91%, 1.12, 1.0, 8%, 92%, and 0.01 for straining to void, and 18%, 89%, 1.6, 0.92, 13%, 92%, and 0.07 for the symptom of slow urine stream. It was concluded that symptoms of obstructive voiding do not correlate with measured post-void urine volume. In clinically important situations, these symptoms cannot substitute for measurement of post-void residual urine volume.

Incidence and predictors of prolonged urinary retention after TVT with and without concurrent prolapse surgery.
Sokol AI, Jelovsek JE, Walters MD, Paraiso MF, Barber MD. Am J Obstet Gynecol 2005 May;192(5):1537-43.

OBJECTIVES: The purpose of this study was to describe the time to adequate voiding, incidence of urinary retention, and predictors of voiding efficiency and urinary retention after tension-free vaginal tape (TVT) with and without concurrent prolapse surgery. STUDY DESIGN: Medical records of patients who underwent TVT between August 1999 and July 2003 were reviewed. Urinary retention was defined as the need for urethrolysis, urethral dilation, or postoperative catheterization for >6 weeks. Linear and logistic regression models were used to determine predictors of time to adequate voiding and urinary retention. RESULTS: Two hundred sixty-seven patients were available for analysis; 66% had concurrent prolapse repair, 4% had concurrent laparoscopically assisted vaginal hysterectomy (LAVH), and 30% had an isolated TVT. TVT with and without concurrent prolapse repair or LAVH were statistically similar with respect to median days to voiding (8 vs 5) and the rate of urinary retention (11.2% vs 11.3%). Overall, 4.9% underwent urethrolysis, 1.9% received urethral dilation, and 4.1% required prolonged catheterization. Increasing age, decreasing BMI, and postoperative urinary tract infection were independent predictors of time to adequate voiding. Previous history of incontinence surgery was the only independent predictor of urinary retention (Adjusted odds ratio [AOR] 2.96, 95%CI [1.17-7.06]). CONCLUSION: Concurrent prolapse surgery does not appear to significantly alter postoperative voiding efficiency or increase the risk of prolonged urinary retention compared with TVT alone.

[The usefulness of clinical history for the diagnosis of lower urinary tract obstruction in patients with acute urinary retention].
Virseda Chamorro M, Diz Rodriguez R, Cancho Gil MJ, Cabrera Cabrera JA, Panos Lozano P, Salinas Casado J. Arch Esp Urol 2005 Apr;58(3):199-206.

To determine the diagnostic usefulness of data provided by clinical history for the diagnosis of lower urinary tract obstruction in patients with acute urinary retention. METHODS: We performed a transversal study in a series of 70 patients (19 women and 51 men) with a mean age of 61.5 years (typical deviation 20.7 years), who underwent urodynamic study due to acute urinary retention. Past medical history was recorded in all patients. Physical exam was also carried out, evaluating prostate size in males, presence of genital prolapse in females, and neurourological examination. Urodynamic tests consisted on flowmetry, pressure/flow studies with simultaneous perineal electromyography, and voiding cystourethrogram or videocystogram. Student's t mean comparison and chi-square tests were used for the statistical analysis. RESULTS: The only clinical data that showed a statistically significant relationship with obstruction of the lower urinary tract were: age, sex, prostate size, and existence of infrasacral neurological lesion (absence of bulbocavernous reflex). Age > 74 years showed a sensitivity of 71 % for lower urinary tract obstruction and a specificity of 60%. Male sex showed a sensitivity of 88% and specificity of 36%. Prostate size > or ='3d grade II sensitivity was 58% and specificity 82%; and absence of infrasacral lesion a sensitivity of 77% and specificity of 48%. CONCLUSIONS: Provided that a negative result in a test with high sensitivity makes the likelihood of disease low, in women the presence of infrasacral neurogenic dysfunction or age < or ='3d74 years diminish the probability of obstruction in patients with acute urinary retention. On the other side, if a negative result of a test with high specificity increases the probability of having the disease, a prostate size > or ='3d grade II and age > 74 years favour the likelihood of having urinary tract obstruction for a patient with acute urinary retention.

Lateral excision of tension-free vaginal tape for the treatment of iatrogenic urethral obstruction.
Long CY, Tsai EM.
Obstet Gynecol 2005 Jun;105(6):1491-2.

Anterior Urethral Strictures: Etiology and Characteristics.
Fenton AS, Morey AF, Aviles R, Garcia CR.
Urology 2005 May 20;.
OBJECTIVES: To evaluate the etiology and characteristics of symptomatic anterior urethral strictures in a large series of men presenting for urologic treatment in an effort to determine the common themes that may influence possible prevention or treatment strategies. Many questions about the origin and features of contemporary anterior urethral stricture disease remain unanswered. METHODS: The records of 175 men with symptomatic anterior urethral strictures were reviewed. Data were entered both prospectively by careful patient questioning and retrospectively from detailed chart review. The stricture length, location, and cause were recorded from urologic presentation, before definitive treatment. Posterior strictures from pelvic fracture urethral disruption defects were excluded from this review. RESULTS: A total of 194 strictures were identified in 175 men. Most strictures were idiopathic (65 of 194, 34%) or iatrogenic (63 of 194, 32%); fewer were inflammatory (38 of 194, 20%) or traumatic (28 of 194, 14%). Most involved the bulbar urethra (n = 100, 52%). Pendulous strictures (mean 6.1 cm) were longer on average than those in the fossa navicularis (mean 2.6 cm) or bulb (mean 3.1 cm). Prolonged catheterization (n = 26) and transurethral surgery (n = 25) were common causes of iatrogenic strictures. CONCLUSIONS: Our results showed that idiopathic and iatrogenic strictures are surprisingly common. External trauma was a relatively uncommon cause of anterior urethral stricture disease overall. Unnecessary urethral catheterization and repeated urethral instrumentation should be avoided to prevent stricture formation or exacerbation. More study is necessary to determine the origin of anterior urethral stricture disease.

Nocturia in men with lower urinary tract symptoms is associated with both nocturnal polyuria and detrusor overactivity with positive response to ice water test.
Hirayama A, Fujimoto K, Matsumoto Y, Hirao Y.
Urology 2005 May 11;.

OBJECTIVES: To investigate whether detrusor overactivity (DO) and the response to the ice water test (IWT) influence nighttime urinary frequency in patients with lower urinary tract symptoms. METHODS: A total of 114 patients with lower urinary tract symptoms, who were older than 50 years, with an International Prostate Symptom Score 8 or more points and a quality of life index of 2 or greater, were evaluated by a 48-hour frequency-volume chart, free flowmetry, pressure flow study, and IWT. RESULTS: The DO-positive IWT responders had a significantly greater bladder outlet obstruction index than did the DO-positive IWT nonresponders and the DO-negative IWT nonresponders. The DO-positive IWT responders had significantly more frequent nocturia and smaller nighttime maximal and minimal voided volumes than did the DO-negative IWT nonresponders without any difference in the nocturnal voided volume. The patients with nocturia two or more times had a significantly larger nocturnal voided volume and smaller nighttime minimal voided volume than the patients with nocturia less than two times. The incidence of DO-positive IWT responders was significantly greater among the patients with nocturia three or more times than that among those with nocturia less than three times. In the multivariate logistic model, the nocturnal voided volume and nighttime minimal voided volume were independently associated with nocturia two or more times and the DO-positive IWT responders were independently associated with nocturia three or more times. CONCLUSIONS: Once high-grade bladder outlet obstruction induces C-fiber-related DO, it is strongly suggested that this process, together with nocturnal polyuria, plays an important role in the consequent clinical manifestations of nocturia in patients with lower urinary tract symptoms.

Prevention of chronic urinary retention in orthotopic bladder replacement in the female.
Puppo P, Introini C, Calvi P, Naselli A
Eur Urol 2005 May;47(5):674-8; discussion 678. Epub 2005 Jan 4.

OBJECTIVE: Chronic urinary retention is a frequent complication after orthotopic bladder replacement. Herein a new technical modification to avoid voiding dysfunction is described. METHODS: Between January 1995 and January 2004, 62 women had orthotopic bladder replacement after radical cystectomy. From November 1998 on, 35 patients were operated using a new technical modification, consisting in the fixation of a large and thick flap of peritoneal and extraperitoneal tissue deriving from the posterior wall of the vagina to the edges of endopelvic fascia to create a resistant hammock under the reservoir. RESULTS: 25 women have a follow-up longer than 12 months, range 12-56, and are considered in this study. Only one, out of 25 patients, still has occasionally stress incontinence but she did not need to use pads. Two patients are incontinent at night. None of 25 patients has a residual urine volume greater than 100 ml or needed intermittent catheterization. Median bladder capacity is 350 ml, range 280-430 ml. Median creatinine level is 1.1 mg/dl, range 0.7-1.2 mg/dl. CONCLUSION: The creation of a posterior support to the neobladder, by harvesting a thick flap, has, in our series, completely avoided the occurrence of chronic urinary retention, which is the most common long-term complication of bladder replacement in the female. Our series is sufficiently large to exclude serendipity and to be compared with other series in the literature.

Lymphangioleiomyomatosis presenting as bladder outlet obstruction.
Scales CD Jr, Springhart WP, Young MD, Anger JT, Leder RA, Preminger GM
Urology 2005 Mar;65(3):589-90.

Structural assessment of the urethral sphincter in women with urinary retention.
Andrich DE, Rickards D, Landon DN, Fowler CJ, Mundy AR
J Urol 2005 Apr;173(4):1246-51.

PURPOSE: The pathophysiology of urinary retention in women is generally unknown but a subgroup of women with urinary retention have been diagnosed as having so-called primary disorder of sphincter relaxation on the basis of an abnormal urethral sphincter electromyogram. It was suggested this sphincter overactivity could lead to work hypertrophy of the urethral rhabdosphincter and in this study we looked for any evidence of such muscle fiber hypertrophy. MATERIALS AND METHODS: In 9 women 18 to 45 years old (mean age 31.6) with urinary retention and overactive urethral sphincter electromyogram, light and electron microscopy were used to examine core needle biopsies of the urethral rhabdosphincter taken under transvaginal ultrasound control. Of the 9 patients only 5 biopsies processed for light microscopy and 4 processed for electron microscopy contained striated urethral muscle fibers. The results of these biopsies were compared to the morphology of a control specimen from a postmenopausal woman without a history of urinary retention. RESULTS: On light microscopy the urethral rhabdosphincter fiber diameter did not differ among patients (mean average 7.6 mum), was less than that reported in the literature (15 to 20), but did not differ from that of the control (mean 9.9). In all patients electron microscopy showed excessive peripheral sarcoplasm with lipid and glycogen deposition, and sarcoplasmic accumulation of normal mitochondria. These ultrastructural abnormalities were not seen in the control. CONCLUSIONS: To our knowledge this is the first morphological description of the urethral rhabdosphincter in a subgroup of women with urinary retention. Mean rhabdosphincter fiber diameter was approximately the same in patients and controls. This study does not support the previous theory that urethral sphincter overactivity in a subgroup of women with urinary retention leads to work hyperplasia of urethral rhabdosphincter fibers. An alternative hypothesis is suggested.

Effect of age on rabbit bladder function and structure following partial outlet obstruction.
Agartan CA, Whitbeck C, Chichester P, Kogan BA, Levin RM
J Urol 2005 Apr;173(4):1400-5.

PURPOSE: We determined whether young and old rabbits respond differently to partial bladder outlet obstruction. MATERIALS AND METHODS: A total of 16 male New Zealand White rabbits were separated into 2 groups of 8 each. Group 1 consisted of young rabbits (age 7 weeks) and group 2 consisted of old rabbits (age 2 years). Four rabbits per group underwent partial outlet obstructions and 4 underwent sham operation. Four weeks following surgery individual bladder strips were used for contractile studies and the remaining tissue was examined histologically. RESULTS: Contractile responses to all forms of stimulation between the young and old sham operated groups were similar. Contractile responses to all forms of stimulation were significantly decreased to the same degree in the 2 obstructed groups. However, the rate of tension generation to field stimulation was decreased to a significantly greater degree in young vs old bladders. Although young and old bladders showed smooth muscle hypertrophy, older rabbits showed significantly greater thickening of the serosa than young rabbits. Young rabbits showed significant inflammation, hemorrhage and expansion of the lamina propria, whereas old rabbits showed none of these characteristics. CONCLUSIONS: Although there were only minor differences in the physiological response of young and old bladders to obstruction, young rabbits showed a significantly greater degree of histological damage. This may have been due to the thinner wall and greater sensitivity to distention.

Urinary retention and obstructive nephropathy secondary to mullerian duct cyst in an adult.
Noon AP, Adeyoju AA, Lynch N
Urology 2005 Mar;65(3):587-8.

Use of alpha(1)-Blockers in Female Functional Bladder Neck Obstruction.
Pischedda A, Pirozzi Farina F, Madonia M, Cimino S, Morgia G
Urol Int 2005;74(3):256-61.

Introduction: Bladder outflow obstruction may cause obstructive or irritative symptoms. The diagnosis of female functional bladder neck obstruction requires a pressure/flow study and electromyography performed by videourodynamics. The treatment includes self-catheterization or bladder neck incision. We administered tamsulosin, an alpha(1)A/alpha(1)D-selective adrenergic antagonist, in women with functional bladder neck obstruction to evaluate its potential therapeutic effects. Patients andMethods: A group of 18 women affected by functional bladder neck obstruction was selected. The diagnosis was made by means of a pressure/flow study combined with electromyography and a fluoroscopic test. The diagnostic criteria were: high detrusor pressure with reduced maximum flow, silent electromyography activity, and bladder neck nonfunnelling during the fluoroscopic test. Tamsulosin 0.4 mg once daily was administered for at least 30 days. Patients with a postvoid residual urine volume >/=100 ml performed intermittent self-catheterization. Patients with a postvoid residual urine volume <100 ml performed self-catheterization every 7 days. After 30 days of therapy, all patients underwent a new pressure/flow study and a micturition fluoroscopic test. Results: 10 (56%) out of 18 treated patients showed a statistically significant improvement in symptoms, maximum flow, and postvoid residual urine volume (p < 0.01). Conclusion: The use of alpha(1)-blockers may be an initial treatment option for female functional bladder neck obstruction, as this therapeutic option proved to be effective in more than 50% of our patients suffering from this voiding dysfunction.

Voiding dysfunction in young, nulliparous women: symptoms and urodynamic findings.
Rosenblum N, Scarpero HM, Nitti VW
Int Urogynecol J Pelvic Floor Dysfunct 2004 Nov-Dec;15(6):373-7; discussion 377. Epub 2004 Jul 8.

The objective was to determine urodynamic findings in young, premenopausal, nulliparous women with bothersome lower urinary tract symptoms and assess whether or not symptoms are predictive of specific urodynamic abnormalities. The records of 57 women were reviewed. Those with neurological disease or a primary complaint of stress incontinence were excluded. All completed the American Urological Association Symptom Index (AUASI) and underwent videourodynamics. Symptoms were compared in patients with and without bladder dysfunction and/or voiding phase dysfunction. Bladder dysfunction was diagnosed in 86% of patients with urge incontinence vs. 17% of those without (p<0.0001). Patients with voiding phase dysfunction had higher total and voiding AUASI scores. Occult neurological disease was later diagnosed in 4 women (24%) with urge incontinence and bladder dysfunction. Urge incontinence and voiding symptoms are frequently associated with urodynamically demonstrable abnormalities. Urge incontinence and bladder dysfunction may be a sign of occult neurological disease in this population. The presenting symptoms are useful in determining the utility of urodynamics in this population.

Type IV sacrococcygeal teratoma causing urinary retention: A rare presentation.
Galili O, Mogilner J
J Pediatr Surg 2005 Feb;40(2):E18-20.

Abstract Sacrococcygeal teratoma is a rare fetal neoplasm usually diagnosed antenatally and considered benign with no functional impairment. Nevertheless, fetuses with this malformation are at risk of significant perinatal morbidity and mortality, usually implying a malignant component. Management is primarily surgical, with a generally good prognosis. Herein, the authors present a rare and unusual presentation of a type IV sacrococcygeal teratoma as urinary retention in a 7-day-old infant. The diagnostic workup and subsequent surgical treatment are described. The nature of the tumor and the treatment is discussed, emphasizing the need for urgent surgical treatment because of bilateral hydronephrosis that failed to resolve after inserting a urinary catheter.

Transurethral incision of bladder neck in treatment of bladder neck obstruction in women.
Peng CH, Kuo HC
Urology 2005 Feb;65(2):275-8.

OBJECTIVES: To report our preliminary experience with transurethral incision of the bladder neck in the treatment of female voiding dysfunction due to bladder neck obstruction. Bladder neck obstruction in women is an infrequently diagnosed urologic condition. METHODS: Bladder neck obstruction was diagnosed in 11 women 41 to 80 years of age, who presented with difficult micturition or urinary retention. Preoperative investigations included a full urodynamic examination and urethrocystoscopy. Transurethral bladder neck incision was performed in all patients. Urodynamic results and clinical improvement in voiding symptoms were assessed. RESULTS: Of the 11 patients, 5 had chronic urinary retention and 6 had difficult micturition; 3 also had recurrent urinary tract infection or upper urinary tract deterioration. The most frequent findings on video-urodynamic study were a high voiding pressure plus low flow rate and a narrow bladder neck during voiding on cinefluoroscopy. After treatment, the lower urinary tract symptoms were resolved or improved in all patients. Ten patients resumed spontaneous voiding with a small postvoid residual urine volume; the remaining patient was able to void by abdominal straining after adjuvant urethral botulinum A toxin injection. Urodynamic study revealed a decreased voiding pressure and postvoid residual urine volume and an increased maximal flow rate. The overall satisfactory rate was 91%. CONCLUSIONS: Transurethral incision of the bladder neck is effective in relieving voiding difficulty owing to anatomic or functional bladder neck obstruction in women. A full video-urodynamic evaluation is essential in making the correct diagnosis and formulating a treatment plan.

Alfuzosin 10 mg once daily in the management of acute urinary retention: results of a double-blind placebo-controlled study.
McNeill SA, Hargreave TB, Roehrborn CG
Urology 2005 Jan;65(1):83-9; discussion 89-90.

OBJECTIVES: To study the impact of alfuzosin 10 mg once daily (OD) on the outcome of a trial without catheter (TWOC) after a first episode of acute urinary retention (AUR) related to benign prostatic hyperplasia (BPH) and the subsequent management of BPH in these patients. METHODS: A total of 360 patients underwent emergency catheterization and were blindly randomized to alfuzosin 10 mg OD or placebo for 3 days (first phase). All patients with successful TWOC, regardless of treatment, were then again blindly randomized to alfuzosin 10 mg OD or placebo for 6 months (second phase). The need for BPH surgery (primary endpoint) was assessed after 1, 3, and 6 months of treatment. RESULTS: Alfuzosin significantly increased the successful TWOC rate (146 of 236, 61.9%) compared with placebo (58 of 121, 47.9%; P = 0.012). In the second phase, 14 (17.1%) of the 82 alfuzosin-treated patients versus 20 (24.1%) of the 83 placebo-treated patients required BPH surgery, 5 (36%) of 14 versus 13 (65%) of 20 within 1 month, and 8 (57%) of 14 versus 17 (85%) of 20 within 3 months of treatment. Emergency surgery because of AUR relapse was the main cause of failure in both groups (11 [78.6%] of 14 in the alfuzosin group and 16 [80.0%] of 20 in the placebo group). Compared with placebo, alfuzosin improved the Kaplan-Meier survival rates by 9.6% (P = 0.04), 11.4% (P = 0.04), and 8.3% (P = 0.20), with surgical risk reductions of 61%, 52%, and 29% at 1, 3, and 6 months of treatment, respectively. High prostate-specific antigen values and the post-TWOC residual urine volume significantly increased the risk of AUR relapse and BPH surgery. Alfuzosin 10 mg OD was well tolerated. CONCLUSIONS: Alfuzosin 10 mg OD increased the likelihood of successful TWOC in men with a first episode of spontaneous AUR and should be continued beyond the acute phase, as it reduced the need for BPH surgery during a 6-month treatment period.

Early postpartum voiding dysfunction: incidence and correlation with obstetric parameters.
Groutz A, Hadi E, Wolf Y, Maslovitz S, Gold R, Lessing JB, Gordon D
J Reprod Med 2004 Dec;49(12):960-4.

OBJECTIVE: To investigate the incidence and obstetric risk factors in early postpartum voiding dysfunction. STUDY DESIGN: Two hundred seventy-seven consecutive women in the early postpartum period were prospectively enrolled. Evaluation included history, physical examination, urinary questionnaire and non-invasive uroflowmetry measurements. Patients were interviewed regarding the presence and severity of voiding symptoms and were categorized into symptomatic versus asymptomatic subgroups. Obstetric parameters were compared in symptomatic versus asymptomatic patients as well as in cases of decreased (< 15 mL/sec) versus normal maximum urinary flow rates. RESULTS: One hundred twenty-five women (45% of the study population) hadearly postpartum voiding difficulties. Symptoms were significantly more common after vacuum extraction (38%) than spontaneous vaginal delivery (27%) or cesarean section (15%). The second stage of labor was significantly prolonged in symptomatic versus asymptomatic patients (62+/-52 versus 47+/-48 minutes). Voided volume, maximum and average flow rates and continuous flow pattern were significantly decreased in symptomatic versus asymptomatic patients. Twenty-eight patients (10%) demonstrated decreased (<15 mL/sec) maximum flow rates. The first stage of labor was significantly prolonged in these patients (9.7+/-5.8 versus 6.4+/-3.9 hours). Twenty-five patients (13%) gave birth to a neonate weighing > or =3,800 g. Maximum flow rates among these women were significantly decreased as compared to women with smaller infants (25.6+/-11 versus 32.9+/-19.2 mL/sec, respectively). CONCLUSION: Approximately 50% of patients complained of voiding difficulties in the immediate postpartum period. Main risk factors were prolonged first and second stages of labor, vacuum extraction and birth weight > or = 3,800 g. Long-term follow-up is needed to determine the significance of this clinically common entity.

Postoperative ureteral obstruction after confirmed ureteral patency: a case report.
Jarnagin B
Int Urogynecol J Pelvic Floor Dysfunct 2004 Sep-Oct;15(5):356-7. Epub 2004 May 18.

Ureteral injury after pelvic floor surgery and anti-incontinence surgery is a well-known risk. It is common practice to evaluate ureteral patency immediately after surgery prior to leaving the operating theater to assure that the ureters are open and functional. In this report we discuss the case of a patient who was admitted 9 days after surgery with acute onset of ureteral obstruction after having patent ureters documented at the time of surgery. A literature search failed to show any documented cases.

Symptoms of voiding dysfunction: what do they really mean?
Dietz HP, Haylen BT
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan-Feb;16(1):52-5. Epub 2004 Aug 03.

Many women presenting with pelvic floor dysfunction will complain of voiding symptoms. This study examines the relationship between such symptoms and uroflowmetry parameters in 414 women with complaints of pelvic floor dysfunction who underwent free uroflowmetry with a weight transducer type flowmeter. Symptoms of voiding dysfunction were ascertained by interview, with symptoms rated positive if they occurred more than occasionally. Symptoms were correlated with maximum urine flow rate and maximum urine flow rate centiles: 356 women voided between 50 and 600 ml; these datasets were used for analysis. Average age was 57.4 years (range: 17-86). Symptoms of voiding dysfunction were common (62%): 26% of women described hesitancy, 28% a poor stream, 26% stop- start voiding, 15% straining to void, and 35% incomplete emptying/need to revoid. As a group, symptoms of voiding dysfunction were associated with reduced maximum urine flow rate centiles (28.1 vs 36.3, p= 0.011). The strength of the association varied markedly, with only hesitancy (p=0.002), poor stream (p<0.001), and stop-start voiding (p=0.014) reaching significance. Hesitancy, poor stream, and stop-start voiding were the only symptoms predictive of voiding impairment. Straining to void and the sensation of incomplete emptying or the need to revoid were not associated with a significant reduction in maximum flow rate centiles.

Do subjective symptoms of obstructive voiding correlate with post-void residual urine volume in women?
Al-Shahrani M, Lovatsis D
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan-Feb;16(1):12-4. Epub 2004 Jul 29.

The objective was to determine if symptoms of obstructive voiding correlate with post-void residual urine volume measured by catheterization. A cross-sectional study of 134 consecutive women referred to a tertiary urogynecology clinic was performed. Subjects were interviewed regarding three types of obstructive voiding symptoms: a sensation of incomplete emptying, straining to void, and slow urine stream. Post-void residual urine volume was measured by catheterization as the gold standard. Data for each symptom were analyzed using Cohen's kappa test, sensitivity, specificity, likelihood ratios for a positive of negative test, and positive and negative predictive values. A total of 11 out of 134 patients (8%) had a post-void residual volume greater than 100 ml. Of these 11, 1 had symptoms of incomplete emptying (9%), 1 had symptoms of straining to void (9%), and 2 had symptoms of slow urine stream (18%). Sensitivity, specificity, likelihood ratio for a positive symptom, likelihood ratio for a negative symptom, positive predictive value, negative predictive value, and Cohen's kappa, respectively, were 9%, 80%, 0.47, 1.13, 4%, 91%, and 0.05 for the symptom of incomplete emptying, 9%, 91%, 1.12, 1.0, 8%, 92%, and 0.01 for straining to void, and 18%, 89%, 1.6, 0.92, 13%, 92%, and 0.07 for the symptom of slow urine stream. It was concluded that symptoms of obstructive voiding do not correlate with measured post-void urine volume. In clinically important situations, these symptoms cannot substitute for measurement of post-void residual urine volume.