Fig. 18.1
CMG: slightly decreased cystometric bladder capacity (~330 mL); no DO; high compliance; no leak with valsalva maneuver; incomplete emptying on PFS with high-pressure, low-flow pattern (P det@Q max = 57 cm H2O); PVR = 115 mL
Cystoscopy: Trilobar prostatic hypertrophy, very large median lobe, bladder trabeculations.
CT (for microscopic hematuria work-up): Very large median lobe (Fig. 18.2).
Fig. 18.2
CT: very large median lobe of the prostate
Diagnosis: BOO due to benign prostatic obstruction (BPO).
Options: Continue α-blocker and 5-αRI, transurethral resection of prostate (TURP), suprapubic prostatectomy.
Commentary: This gentleman has clear evidence of BOO and options for relieving outlet resistance are effective in improving symptoms.
Case 2: 67 years of man presents for evaluation of UUI.
History: He complains of diurnal urgency, urinary frequency (10/day, 3/night), and UUI requiring 3–4 pads/24 h. He has subjective incomplete emptying. He denies weak stream or straining to urinate. DRE: 35 g benign prostate. The remainder of his history and exam are normal.
Course: Prostate specific antigen (PSA) is 0.45 ng/mL. Patient has been on dual therapy with α-blocker and 5-αRI for over a year and has also tried multiple muscarinic receptor antagonists (anticholinergics) in past without significant subjective improvement.
Urodynamics (Fig. 18.3): First sensation occurred at 106 mL, strong desire at 178 mL, and cystometric bladder capacity was 247 mL; Two episodes of DO at 150 mL of filling (pressures from 12 to 22 cm H2O). Both were associated with urgency but no leakage; high compliance; no leakage with cough or valsalva; during PFS (Fig. 18.4), P det@Q max = 65 cm H2O, P detmax = 84 cm H2O with a flow of 13.4 mL/s; Bladder Outlet Obstructive Index (BOOI) = 57.
Fig. 18.3
CMG: first sensation at 106 mL; strong desire at 178 mL; cystometric bladder capacity at 247 mL; two episodes of DO at 150 mL of filling (pressures = 12–22 cm H2O); both episodes associated with urgency but no leakage; high compliance; no leakage with cough or valsalva
Fig. 18.4
PFS: P det@Q max = 65 cm H2O; P detmax = 84 cm H2O; flow = 13.4 mL/s; Bladder Outlet Obstructive Index (BOOI) = 57
Cystoscopy: Posterior urethra remarkable for high bladder neck with co-apting lateral lobes; moderate bladder trabeculations; small-bladder diverticulum.
Diagnosis: DO and BOO (due to BPO).
Options: Additional anticholinergics, β-3 adrenergic agonist, sacral neuromodulation, intravesical onabotulinumtoxinA injection, TURP.
Commentary: The BOOI = P det@Q max − 2 × Q max, with a value <20 representing no obstruction, 20–40 representing an equivocal result, and >40 representing obstruction. This gentleman has both a problem during bladder filling (DO) and voiding (BOO). As such, he may require more than one treatment to alleviate his symptoms. While TURP may improve his BPO, he may continue to have bothersome storage symptoms. Conversely, medical or surgical treatment of his DO is unlikely to improve, and, in some cases may negatively impact his voiding.
Case 3: 50 years of woman with progressively worsening emptying.
History: She urinates frequently during day (diary: 10–14 voids/day, 2 voids/night; volumes 100–200 mL) and strains to urinate; (+) incomplete emptying; denies SUI or UUI; (+) UTIs, 2–3/year; (+) lumbar back injury after MVA 7 years ago; no spinal or pelvic surgery; (+) constipation; no pelvic prolapse on examination.
Course: She has not tried any active therapy.
Urodynamics: Unable to perform pre-procedure UF (Fig. 18.5; catheterized PVR = 350 mL); delayed first desire (Fig. 18.6; 693 mL); large bladder capacity (>800 mL); no DO; high compliance; unable to generate coordinated detrusor contraction during PFS (Fig. 18.7); PVR at end of procedure >1,000 mL.
Fig. 18.5
Patient was unable to perform pre-procedure UF (catheterized PVR = 350 mL)
Fig. 18.6
CMG: delayed first desire (693 mL); large bladder capacity (>800 mL); no DO; high compliance
Fig. 18.7
PFS: patient unable to generate coordinated detrusor contraction; PVR at end of procedure > 1,000 mL
Diagnosis: Urinary retention due to detrusor acontractility.
Options: CIC, sacral neuromodulation.
Commentary: This patient’s symptoms stem from suboptimal emptying due to a lack of detrusor contractility. Her upper tracts are likely safe owing to high compliance and absence of DO. Her volitional voids during the day are most likely due to either valsalva voiding or overflow events.
Case 4: 55 years of man with overactive bladder symptoms.
History: He complains of urinary urgency and UUI 1–2 days/week. He voids 8/day and 2/night. Stream is “fair.” He has tried two anticholinergics without significant benefit. He has had one recent culture-proven UTI (E. coli). Patient is otherwise healthy. DRE: 60 g benign prostate. He had a PVR of 198 and 187 mL on two consecutive visits.
Course: He had minimal improvement after a combination of an anticholinergic and α-blocker.
Urodynamics: Pre-CMG UF reveals Q max 20 and continuous flow curve with adequate voided volume (277 mL; Fig. 18.8); PVR is high (375 mL); delayed first desire on CMG (463 mL; Fig. 18.9) and delayed normal desire (810 mL); no DO; high compliance; high-pressure, low-flow pattern on PFS (Fig. 18.10), small volume void, high PVR; low-flow and high PVR on post-PFS UF (Fig. 18.11).
Fig. 18.8
Pre-CMG UF: Q max = 20 mL/s with continuous flow curve with adequate voided volume (277 mL); PVR = 375 mL
Fig. 18.9
CMG: delayed first desire to void (463 mL); delayed normal desire (810 mL); no DO; high compliance
Fig. 18.10
PFS: high-pressure, low-flow pattern; small-volume void; high PVR
Fig. 18.11
Post-PFS UF: low-flow; high PVR
Cystography: Large posterior bladder diverticulum (bladder is on the left) (Fig. 18.12); attempt to void (Fig. 18.13); post-void film showing empty bladder and full diverticulum (Fig. 18.14).
