Bladder Outlet Obstruction: Male Non-neurogenic

Fig. 7.1

Urodynamics tracing in a patient with Parkinson’s disease and urinary retention

Fig. 7.2

Pressure-flow diagram in a patient with Parkinson’s disease and urinary retention

Findings

At the beginning of the urodynamics procedure, uroflowmetry was attempted; however, the patient was unable to void. A Foley catheter was placed for the procedure and 300 mL of clear yellow urine was drained.

Filling Phase

First desire to void at 470 mL.
Normal desire at 522 mL.
Cystometric capacity was 541 mL.
No DO noted.
No stress urinary incontinence or urge urinary incontinence.
Normal compliance.
Normal EMG activity.

Voiding Phase

Q _max of 3.6 mL/s.
P _det Q _max of 62.7 cm H₂O.
Void a volume of 72 mL.
PVR was 468 mL.
EMG activity was synergic.

Urodynamic evaluation in this patient demonstrated decreased bladder sensation with a normal bladder capacity. The uroflow rate was decreased at 3.6 mL/s, and the pattern of flow was plateaued. Detrusor contractility was normal. The patient demonstrated an obstructed bladder outlet and incomplete bladder emptying with a PVR volume of 468 mL. The intravesical voiding pressure was increased at 62.7 cm H₂O.

7.2.1.5 Treatment Options

In this patient who demonstrated decreased bladder sensation, likely secondary to Parkinson’s disease, and evidence of BOO, the decision about the best option for treatment must weigh the risks and benefits of surgical options compared to less invasive options. While combined therapy with an alpha-blocker and 5-alpha-reductase inhibitor is a reasonable first option, this patient has failed multiple voiding trials on this regimen after a number of months of treatment. Therefore, an alternative treatment strategy is necessary. CIC would be reasonable in a patient with a limited life expectancy or in a patient unfit to undergo surgical intervention. However, given that this patient has already experienced two urinary tract infections with sepsis requiring hospitalization in a short period of time, surgical intervention is preferable to CIC. In a patient such as this with a moderately large prostate size of approximately 70–80 g, a transurethral resection of the prostate (TURP) is a reasonable option, though a laser vaporization of the prostate could also be considered. Alternative outpatient treatments such as transurethral microwave therapy would be less likely to treat this patient’s outlet obstruction adequately.

This patient elected to undergo a TURP. Following the procedure, he was immediately able to void with a PVR volume of approximately 50 mL.

7.2.2 Patient 2

7.2.2.1 History

The patient is a 74-year-old male patient who presented to the outpatient Urology clinic complaining of multiple episodes of urinary retention. This was accompanied by nocturia 4–5 times per night, straining to void, and a weak urinary stream. His primary care provider previously started him on tamsulosin, though he continued to experience episodes of urinary retention with complete inability to void. On initial presentation to the Urology clinic, he was started on finasteride, though after 6 weeks of therapy his PVR volume remained at 75 mL and uroflow demonstrated a reduced Q _max of 4 mL/s.

7.2.2.2 Physical Examination

General: no acute distress, appearing his stated age
Psychologic: no signs of depression
Neurologic: no deficits
Cardiovascular: no labored breathing or extremity edema
Abdomen: soft, nontender, and nondistended
Genitourinary: no costovertebral angle tenderness, an uncircumcised phallus, a normal rectal tone, and an approximately 80–90-g prostate on digital rectal exam

7.2.2.3 Lab Work /Other Studies

Creatinine obtained to check the patient’s renal function was 1.7, higher than his previous baseline of 1.
UA and urine culture were negative.
A transrectal ultrasound was also performed, demonstrating a 90-g prostate gland.

7.2.2.4 UDS

See Figs. 7.3 and 7.4.

Fig. 7.3

Urodynamics tracing in a patient with a history of multiple episodes of urinary retention and failed dual medical therapy for BPH

Fig. 7.4

Pressure-flow diagram in a patient with a history of multiple episodes of urinary retention and failed dual medical therapy for BPH

Findings

Filling Phase

First sensation to void at 87 mL.
First desire to void at 112 mL.
Normal desire to void at 158 mL.
Cystometric capacity was determined to be 355 mL.
No DO noted.
No evidence of stress urinary incontinence or urge urinary incontinence.
Compliance normal.
EMG activity normal.

Voiding Phase

Q _max was determined to be 4.6 mL/s.
P _det at Q _max was 76.3 cm/H₂O.
Voided volume of 175 mL.
PVR volume was 180 mL.
EMG activity was synergic.

This urodynamic evaluation in this patient demonstrated a normal filling and storage phase with normal bladder sensation, normal bladder capacity, and no detrusor instability. The patient did, however, demonstrate evidence of BOO during the voiding phase of the study. This is evidenced by an increased intravesical voiding pressure and low flow rate. Additionally, the patient demonstrated incomplete bladder emptying. At the end of the procedure, the urodynamics catheter was removed, and the patient was again asked to attempt to void. He was able to void an additional 105 mL at a Q _max of 4 mL/s, with a PVR volume of 75 mL.

7.2.2.5 Treatment Options

In patients for whom medical management of presumed BOO secondary to BPH has failed, a thorough assessment of bladder function with UDS and prostate volume should be undertaken. A digital rectal exam may give a crude estimate of prostate volume and should be the initial step in assessing prostate size in these patients. In patients with suspected large volume glands, a transrectal ultrasound may be performed to better quantify the exact volume of the prostate gland and may aid in surgical planning. Additionally, a cystoscopy is a reasonable option to assess bladder and prostate architecture, though it is not necessary. In patients with large volume glands such as this, an open simple prostatectomy has been the standard of care in allowing the greatest amount of adenoma to be removed. Alternatively, as of late, a robotic approach to simple prostatectomy has been described and allows a minimally invasive approach to prostate enucleation [26]. Additionally, some authors have incorporated routine use of holmium and thulium laser fibers to enucleate the prostate adenoma via a transurethral approach. In this case, a holmium laser enucleation of the prostate was undertaken, and a total of 51 g of adenomatous tissue was enucleated. Two years post-procedure, the patient continues to report a significantly improved force of stream and bladder emptying. He has not experienced any additional episodes of urinary retention and continues to have PVR volumes of 0 mL.

7.2.3 Patient 3

7.2.3.1 History

The patient is a 96-year-old male patient with a past medical history remarkable for coronary artery disease and atrial fibrillation, for which he was prescribed aspirin and clopidogrel, who presented to the outpatient Urology clinic complaining of a weak urinary stream, straining to void, and a complete inability to void for the past 12 h. He had previously been diagnosed with BPH and had been prescribed silodosin and dutasteride by his primary care provider. With Valsalva maneuvers, he was able to urinate only a few drops of urine, and a PVR volume measurement demonstrated over 200 mL of residual urine. A Foley catheter was placed at that time and drained 400 mL of clear yellow urine.

Three days after initial catheter placement, the patient returned to the Urology clinic for a trial of void. At this time, however, he was again unable to void, and a Foley catheter was replaced. The decision was made at this time to perform urodynamic testing.