© Springer International Publishing Switzerland 2015
Hadley M. Wood and Dan Wood (eds.)Transition and Lifelong Care in Congenital UrologyCurrent Clinical Urology10.1007/978-3-319-14042-1_1212. BPH and Pelvic Organ Prolapse in Patients with Neurogenic Bladder
(1)
The Arthur Smith Institute for Urology, New Hyde Park, NY, USA
Keywords
Benign prostatic hyperplasiaPelvic organ prolapseBPHPOPNeurogenic bladderIntroduction
The successful management of many diseases that result in neurogenic bladder has allowed patients who were previously only cared for by Pediatric Urologists to live well into adulthood. In the past, patients with myelomeningocele and neurogenic bladder rarely used to live into their third decade. It is now not uncommon for these patients to live significantly longer lives [1]. With this increased longevity comes the myriad of adult Urologic conditions that these patients are now beginning to face, including benign prostatic hyperplasia (BPH) and pelvic organ prolapse (POP). While BPH and POP are common urologic conditions in the general adult population, they present a unique challenge for patients with neurogenic bladder, and relatively little is known about the effects of these disorders in this patient population. This chapter aims to focus on the presentation and management of patients with neurogenic bladder who develop BPH or POP in their adult lives.
Transition of Pediatric Patients with Neurogenic Bladder into Adulthood
The management of neurogenic bladder in childhood depends upon a number of underlying factors, including the dexterity and ability of a patient to perform catheterization or void by Valsalva maneuvers, the etiology of bladder dysfunction, and prevention of adverse sequela such as renal deterioration [2–5]. In a patient with both good manual dexterity and the willingness to catheterize through his or her native urethra, oftentimes clean intermittent catheterization (CIC) presents the most manageable form of bladder decompression [2]. Voiding by Valsalva maneuver also allows many patients with incompetent urethral sphincters to empty their bladders well, without the need for catheterization [6]. In the patient who is unable to catheterize or void by Valsalva, and for whom the concern of renal deterioration, urinary tract infections, pain from frequent urethral catheterization, or reliance on another individual exists, often a urinary diversion procedure such as a Mitrofanoff or Monti-Yang procedure may be performed and allows a greater quality of life in these patients [7, 8].
Until recently, most patients with neurogenic bladder have relied upon the care of Pediatric Urologists for management due to their familiarity with the disease process and previous surgeries, and lack of knowledge of these conditions by adult urologists. Conversely, pediatric urologists are less adept at dealing with the adult urologic conditions that develop in these patients, including malignancies, BPH, and POP. These adult onset urologic issues may present problems in these patients such as difficulty with self or assisted catheterization, issues with voiding by previously acceptable Valsalva maneuvers, and hematuria to include a few dilemmas. Thus, the need to be managed by a practitioner with knowledge of each of these conditions is especially relevant to the aging adult patient with congenital neurogenic bladder.
Patients with Neurogenic Bladder Who Develop BPH or Pelvic Organ Prolapse
Patients with neurogenic bladder typically become accustomed to managing their disease in a certain way. They become comfortable with self-catheterization or Valsalva voiding and are usually fairly happy with the management of their disease. With advancing age and the development of either BPH or POP, which may cause difficulties with these particular management strategies, distress can occur. It may be difficult for practitioners, as well, to determine the etiology of increasing difficulty with a previously effective management strategy. For example, in a 60-year-old male patient with an acontractile neurogenic bladder who has performed CIC for a number of years, does the development of pain and difficulty with catheterization indicate the formation of a stricture or an enlarging prostate? In the aging male who previously did not have difficulty voiding and who empties his bladder well, the development of lower urinary tract symptoms (LUTS) is more likely to signify bladder outlet obstruction from BPH. Similarly, in a 20-year-old male with a neurogenic bladder who routinely performs CIC and develops difficulty with catheterization, stricture formation from chronic catheterization is favored over development of BPH. Similar problems may arise in female patients who void by Valsalva and later develop POP. In these patients, does progressive difficulty voiding signify obstruction from POP or failure to produce adequate intra-abdominal pressure in order to void to completion? Numerous other problems may arise as well, including formation of mucous in augmented bladders [9–11], formation of bladder stones [12, 13], and renal deterioration [14–16]. Weight gain and increased disability associated with aging in the myelomeningocele population may result in increased difficulty accessing the urethra for CIC, particularly in the female patient who is wheelchair-bound and/or the male patient with a buried penis. This often results in management with an indwelling Foley catheter, a solution that predisposes to fistulae, leakage, ulcers, and infections, and should never be utilized as a long-term bladder management solution. All of these obstacles are best managed by a urologist with expertise in these conditions, yet with knowledge of the past surgeries and management of patients with neurogenic bladder.
Presentation and Management of Patients with Neurogenic Bladder Who Develop BPH in Adulthood
Background
Previous studies have demonstrated that prostate growth occurs at a rate of approximately 0.6–2.5 cm3 per year in men over the age of 30, corresponding to an increased volume of roughly 2.5 % per year. In these studies, the highest rate of growth occurred between the ages of 56–65, and then declined for older men [17, 18]. Increased prostate size has implications for men with neurogenic bladder for a number of reasons, including higher residual amounts of urine in men who void by Crede or Valsalva maneuvers, increased pain and difficultly in performing catheterization in men who are managed by CIC, and higher rates of urinary tract infections. In general, men with BPH commonly present with LUTS such as urinary urgency, frequency, hesitancy, nocturia, a weak urinary stream, and feelings of incomplete emptying [19]. In men with neurogenic bladder who void by Valsalva or Crede maneuver, many of these symptoms can be the initial presenting complaint.
Evaluation
In general, in patients with neurogenic bladder who present with complaints suspicious for BPH, a thorough history and physical exam should be completed. A digital rectal exam should be performed to assess the size and shape of the prostate [20]. Concerns for prostate cancer, including a history of weight loss, nodularity on digital rectal exam, and a rising PSA should be managed in the usual manner for workup of prostate cancer, including a PSA test if not already done, and a prostate biopsy when indicated. If the patient is usually able to void by himself, initial evaluation should include a voiding diary and a post-void residual (PVR) volume. Urodynamic evaluation should also be undertaken, both for initial evaluation and when urinary symptoms or PVR change. An assessment of renal function should also be checked annually, although the optimal method of measuring renal function in this select subset of patients remains to be established (reference Kaufman chapter). A urinalysis should be obtained to screen for infection (if the patient is symptomatic), medical renal disease, and glucosuria. If warranted, a urine culture should be sent. Imaging should include a renal ultrasound to evaluate for hydronephrosis in order to assess for upper urinary tract impairment. Urine cytology should be obtained if there is a concern for malignancy, and a cystourethroscopy should be performed to evaluate the urethra for strictures, the prostate for contour and enlargement, and the bladder for evidence of trabeculation or tumors. In patients with diabetes, an assessment for peripheral neuropathy should be performed as hyperglycemic nerve damage may lead to worsening detrusor function [21].
In patients with an atonic, high-pressure, or augmented neurogenic bladder who perform intermittent catheterization, the initial indication that BPH has developed most likely will manifest as difficulty with catheterization [22, 23]. Men will report that they feel it is increasingly difficult to pass a catheter into the bladder while using catheters that previously passed smoothly. A thorough history will elicit that this developed over time, and many men may not present until significant difficulty with catheterization occurs. This undermines the importance of close follow-up in all patients with a neurogenic bladder, but even more so in those who perform CIC. Additionally, patients may present with hematuria, either spontaneous or in combination with catheterization [24, 25]. This is due to the increased size of the prostate and neovascularity of the enlarged gland [26]. When patients present in this way in particular, urothelial malignancy must be ruled out (see Chap. 11).
Complications of BPH and difficulty with catheterization in patients with an atonic, high-pressure, or augmented bladder include prostatitis, urinary tract infections, renal deterioration from increased bladder residual urine volumes, hematuria, and bladder rupture in patients with augmented bladders. In some cases, urinary tract infections and prostatitis may be the initial manifestation that a man is experiencing difficulty with catheterizations. In rare circumstances and in patients with poor follow-up, renal failure or bladder rupture may be the reason for initial presentation.
Workup in these patients should include a thorough history and physical exam with emphasis on the digital rectal exam, as well as laboratory assessment of creatinine in patients for whom there is a concern for renal deterioration [27]. Imaging studies, when indicated on the basis of history and physical, may include a transrectal ultrasound to assess the size of the prostate, a renal ultrasound to evaluate for hydronephrosis, and in some cases a CT scan of the abdomen and pelvis, for example if a concern for urinary tract malignancy exists. A urinalysis and urine culture should be obtained if prostatitis or a urinary tract infection is suspected. Finally, a cystourethroscopy should be performed to assess for urethral stricture and to examine the contour of the prostate [28]. In patients for whom a CT Urogram is contraindicated, such as in patients with renal impairment and elevated creatinine, but for whom evaluation of the upper tracts is necessary, a retrograde pyelogram performed at the time of cystoscopy is an acceptable alternative to CT Urogram.
In a patient with neurogenic bladder who voids by Valsalva maneuvers, a common initial presentation may be the feeling of incomplete emptying, a weaker stream than usual, or a complete inability to void. Patients who void by Valsalva or Crede maneuver have an increased residual urine volume initially, and if BPH develops, the volume of residual urine may increase. This can lead to renal impairment secondary to higher pressures, renal and bladder stones, and hydronephrosis [29].
Patients with neurogenic bladder who void by Valsalva or Crede maneuvers that present with complaints suspicious for BPH should initially have a thorough history and physical exam performed with emphasis on the prostate exam and International Prostate Symptom Score [30]. Prostate volume should be estimated by digital rectal exam. These patients should additionally have a PVR checked as well as serum creatinine. Renal and bladder ultrasound should be performed in any patient for whom renal impairment or renal and bladder stones are suspected. This is especially imperative in patients who have high-pressure neurogenic bladders, as increased pressure from urinary retention can cause severe upper tract impairment [31]. Urodynamic evaluation should also be performed and compared to previous urodynamic testing for the evaluation of bladder pressures, maximum flow rate, and residual urine volume. A cystourethroscopy should be performed if there is any concern for urethral stricture or urothelial malignancy, and in cases in which surgical intervention is planned.
Management strategies in patients with atonic, high-pressure, or augmented neurogenic bladders who perform CIC should aim to preserve renal function, reduce the risk of urinary tract infections and sepsis, maintain dryness, and preserve a good quality of life for patients. In many patients who have enjoyed a good quality of life with CIC, their preference may be to continue a regimen of catheterization. Initial consideration should be given to medical therapy with an alpha-blocker alone or in combination with a 5-alpha reductase inhibitor to reduce the size of the prostate, decrease LUTS, and allow for continued catheterization. Medical management with alpha-blockers and 5-alpha reductase inhibitors has been shown to reduce the risk of clinical BPH progression and reduce BPH symptomatology [32–34]. In patients for whom medical therapy is contraindicated or fails, other options include an indwelling suprapubic catheter, formation of a catheterizable channel (Mitrofanoff), and surgery to reduce the size of the prostate.
It may be tempting to utilize an indwelling Foley catheter as a solution in patients who do not wish to undergo surgery or who are medically unfit, however, the authors caution that this solution invariably leads to greater problems, including clinically significant urinary tract infections, bladder stones, urethral erosion, and in some patients, ongoing discomfort and pain [35–37]. Alternatively, the patient may choose to have a suprapubic catheter placed for bladder decompression. Advantages to this over an indwelling urethral catheter include the ability to obtain bladder decompression in patients for whom passage of a urethral catheter is difficult or impossible, less pain during catheter changes, decreased rates of UTIs, and decreased rates of urethral erosion, and sphincter damage. Disadvantages of a suprapubic tube include the risk of injury to other structures such as bowel during initial placement of the suprapubic tube, risk of dislodgement with transferring from a chair, stone formation, malignancy, and urinary tract infections.
In patients who are deemed to be good surgical candidates and who wish to continue to perform intermittent catheterization, different outlet procedures allow reduction in the size of the prostate and channel opening, thereby permitting continued catheterization [28]. Both transurethral resection of the prostate and laser vaporization of the prostate allow a minimally invasive approach to opening the prostatic urethra. Other procedures such as transurethral microwave thermotherapy and transurethral incision of the prostate may be attempted for small glands, with the realization that further procedures may be necessary. In very large prostate glands in patients who have not had their bladders augmented, open and robotic simple prostatectomy may be considered as well as newer procedures such as Holmium laser enucleation of the prostate (HOLEP). A simple prostatectomy should not be performed, however, in patients who have had their bladders augmented due to the risk of injury to the reconstructed bladder. It is important to consider positioning for patients being considered for office procedures, as central obesity and contractures of the lower extremities may hinder positioning of a patient in lithotomy and baseline cardiopulmonary disease may impair the ability of the patient to lay supine. For such patients, general anesthesia should be considered.
Management of patients with neurogenic bladder who void by Valsalva and who develop BPH is multifaceted. Initial attempts at medical management may be attempted with an alpha-blocker alone or in combination with a 5-alpha reductase inhibitor [32–34]. In patients who do not experience relief of symptoms with medical therapies, further management may include a regimen of CIC or surgeries to open the prostatic urethra, such as TURP or laser vaporization of the prostate. Prostatectomy should be considered in patients with very large prostate glands.
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