Bladder outlet obstruction
(BOO) in women
Ingrid Nygaard, MD, MS
Professor
University of Utah

• Describe both voiding and storage symptoms of BOO in women.
• Understand the association between voiding symptoms of BOO and objective findings of
BOO.
• State the role of urethral dilation in treating
BOO in women.
• Describe the most optimal time period to intervene in BOO following mid-urethral sling.

• Voiding symptoms
– Hesitancy
– Straining
– Incomplete emptying
– Post void dribbling
– Slow stream
– Splayed stream
– Urethral pain
• Storage symptoms
– Urgency, frequency, OAB
– Urgency incontinence

Symptoms of BOO are common in women
• Amongst 297 women, mean age 68, not seeking care:
– Frequency
– Urgency
– Difficulty emptying
– Incomplete emptying
– Weak stream
– Intermittent stream
– Postvoid dribble
29%
29%
13%
21%
19%
26%
7%
(Reported that symptom occurred ‘usually’ during past 3 months.)
Bradley, Kennedy, Nygaard 2005

Hesitancy
Straining
Incomplete emptying
Post void dribble
Weekly
28%
15%
16%
14%
Daily
16%
8%
7%
4%
4,000 Danish women
3/4 had symptom “sometimes”
MØLLER, LOSE, JØRGENSEN. Acta Obstet Gynecol Scand 2000

Given that symptoms are common, how well do they correlate with ‘objective’ evidence of obstruction?

Predictive value of obstructive voiding symptoms and tests
In 95 women visiting urogyn clinic for LUTS:
Positive response Positive Predictive Value
(compared to PVR > 50 ml)
“Do you usually experience feeling of incomplete bladder emptying?”
47% 0.16
Max flow < 10 th % 34% 0.29
Low flow and high pressure during voiding
20% 0.28
[Jeon and Yoo, 2012]

• 636 women presenting to urogyn clinic
• Stage I-II: PVR 41 (SD 51); 3% had PVR > 150 ml
• Stage III-IV: PVR 67 (SD 92); 10% had PVR > 150 ml
• Moderate/great bother by
– feeling incomplete emptying:
• Yes: PVR 56 (SD 78)
• No: PVR 40 (SD 56)
– Difficulty emptying bladder
• Yes: PVR 48 (SD 45)
• No: PVR 44 (SD 48)
[Lowenstein….Brubaker, Int Urogyn J
2008]

• Should we:
– Investigate all women with BOO symptoms?
– Or investigate no women with BOO symptoms and consider these ‘normal findings’?
• My preference: Check PVR and proceed from there.

• Lifestyle factors
• Overactive outlet
• Anatomic obstruction
– Iatrogenic (SUI surgery)
– Pelvic organ prolapse (POP), tumor
– Urethral (traumatic, stenosis, stricture)
– Congenital/neoplasm/DSD/inflammatory
• Behavioral (“Pseudodyssynergia”, “Shy bladder”)

Obstructive symptoms and lifestyle factors
Coffee
• Difficulty emptying reported by
– 15% of coffee drinkers
– 3% non-coffee drinkers
• P=0.01
• Weak stream reported by
– 23% of coffee drinkers
– 5% non-coffee drinkers
• P<0.01
• ORs 5-8 adjusted for age,
BMI, smoking, exercise
Others
• BMI
– Urgency OR 1.8 (0.8, 4.0)
– UUI OR 2.2 (1.0, 4.8)
• Exercise > weekly
– Urgency OR 0.6 (0.4, 1.0)
• Smoking
– No effect on any BOO symptoms
• Age
– Increased odds of most
BOO symptoms
Bradley, Kennedy, Nygaard 2005

• Medications that increase resistance
– Alpha adrenergic agonists (phenylpropanolamine)
– SSRI (duloxetine)
– Beta adrenergic antagonists (propranol)

SUI surgery and subsequent BOO
(UITN studies)
New UUI
Burch (n=329) 3%
Fascial sling (n=326) 3%
0% Retropubic MUS
(n=298)
Transobturator
MUS (n=299)
0.3%
Voiding dysfunction
>6 weeks (catheter or revision)
2%
BOO requiring surgery
0%
14%
3.4%
6%
2.7%
1.3% 0%
Albo, Richter et al. NEJM 2007; Richter, Albo et al. NEJM 2010

Treatment of BOO following midurethral sling
• When?
• Where?
• How?
• NB: STEP 1: Ensure patient is not straining to void!

• 2002: Experience of 4 US centers during early years of TVT
• N=23: Some improvement in 3 of 11 that tried meds and in
1 of 7 that tried dilation
• median interval between TVT and release 8.6 weeks
– 10: general anesthesia
– 13: local and IV sedation
– 1: office with local
• 17 midline lysis only
• 100% relief of impaired emptying by 2 weeks
• Continence status: cure: 61%, improved 30%
Rardin, Rosenblatt, Kohli et al. Obstet Gynecol
2002

Finnish registry by end 2002 ( early days of TVT )
9040: TVT
50 (0.6%): TVT release ( mean 197 days after)
91% midline transection
49%: retention cured and no new SUI
88%: retention cured
Laurikainen, Kiilholma Int Urogyn J 2006

• Delayed intervention: good success at restoring voiding but lower cure rate
• Early intervention : better success at restoring voiding and better cure rate
– And, early timing allows attempts to mobilize sling

• 10 women unable to void after TVT
• Mobilization in OR POD 3-10. All voided and catheter out by 48 hours.
• No difference in continence.
• Bottom line: Mobilize if no void by POD 3.
Nguyen J. Urology 2005

• Mobilization in OR under general anesthesia
– N=33:TVT mobilized and loosened within 2 weeks
– Voiding function normal in 29; 4 underwent later release
• Price…Jackson. International Urogynecology 2009
• Mobilization on floor under local
– 3-0 vicryl loop placed at midpoint of tape and pulled
– 5/80 received mobilization on POD 1-3. Immediately successful in 4, 1 needed 3 adjustments. None had recurrent SUI.
• Chang, Sheu, et al: International Urogynecology 2010

Voiding dysfunction after mid-urethral sling: Bottom line
• Uncommon
• More with retropubic than transobturator approach
• Generally, no pre-op testing, other than PVR, required
• Intervene early
• Try mobilization first
• Early surgical treatment resolves retention about
90% of time; low risk of new SUI

BOO due to anatomic obstruction
Pelvic Organ Prolapse (POP)
1
2
POP-Q stage
0
3,4
PVR*
25 (0-270) [median, range]
30 (0-250)
45 (0-700)
50 (0-350)
*cath, 5 min post void
Cetinkaya et al, 2013

Irritative and obstructive symptoms, and bother
Women with POP and SUI have more bladder symptoms
OR (95% CI) Stress Continent Stress
Incontinent
296 82 No. women
% with bothersome symptoms
Irritative 47% 80% 0.22 (0.11
–0.42)
Nocturia 31% 55% 0.35 (0.20
–0.62)
Enuresis 0.3% 8% 0.05 (0.00
–0.55)
Dysuria 12% 20% 0.67 (0.32
–1.40)
Voiding
PVR
49%
87 ml
72% 0.36 (0.20
–0.66)
66 ml
Richter, Nygaard et al. J Urol 2007

• 35 women undergoing POP op with PVR >100
(mean 226 ml)
• Post op, PVR normal in 89%
• [Fitzgerald, Fenner 2000]
• 57 women undergoing POP op with PVR>100
• Post op, PVR <100 in 84%
• [Liang et al 2008]

• UK survey 2006 of urologists
• Indication
– Urethral stenosis 97%
– LUTS with inadequate bladder emptying 72%
– Idiopathic acute retention: 49%
– Chronic retention: 35%
• How often used in past year?
– 1-3: 18%
– 4-6: 21%
– 7-15: 26%
– 16-30: 20%
– >30: 15%
• In what % of women do you find urethral stenosis?
– < 25%: 69%
– 25-50%: 17%
– 50-75%: 9%
– >75%: 4%
• In what % do you see significant improvement?
– <25%: 17%
– 25-50%: 38%
– 50-75%: 36%
– >75%: 9%
Masarani and Willis, 2006

Is urethral stricture treated by urethral dilation?
Or
Does urethral dilation cause urethral stricture?

BOO Anatomic
Urethral stricture
• Accounts for 4-18% of women with BOO
• Much less prevalent in women
• Etiologies:
– Iatrogenic: Diverticulectomy, fistula repair, SUI surgery, tumor resection, repetitive dilation
– Traumatic: prolonged cath, pelvic fracture
– Infectious: gonorrhea, tuberculosis
– Radiation therapy
• Diagnosis: cystoscopy, urethral calibration
– “In our experience, a urethra too narrow to admit a 17Fr flexible cystoscope that has the feel of scar tissue by haptic feedback is diagnostic.”
– Visual circumferential narrowing
• N=17 in 12 years
• 1 of 17 had sustained response to dilation alone
Blaivas et al. J Urol 2012

• “There is no evidence supporting an appropriate role for urethral dilation (UD) in girls and women with dysfunctional voiding.” “There seems to be no role for UD in pure functional BOO.”
• “The value of UD in treating female urethral stricture disease, a rather rare entity, has not been consistent between studies”
• “UD is a well recognized risk factor for stricture development.”
• Bazi, Abou-Ghannam, Khauli, Int Urogynecol J, 2013

Overactive pelvic floor (aka
Pelvic floor hypertonic disorder) and
BOO
• Primary symptoms: pain, defecation disorder
• Botox studied for pain, vestibulodynia, pelvic floor myalgia, pelvic floor spasm

?Subtype of social anxiety disorder
?Physiologic disorder
May respond to graduated exposure therapy
Shy Bladder Scale recently developed
Only with education and research, in addition to clarification and agreement of the terminology for this phenomenon, can progress be made in understanding and effectively treating paruresis. Soifer…Chancellor. Urol Nurs 2009

Posture on public toilet
Hover (crouch)
• 40% Australian volunteers (Rane, 2007)
• 85% British GYN patients (Moore, 1991)
• 149% increase in PVR in crouch position
• 89% Chinese university students (Yang, 2010)
– 18% bell-shaped flow curve compared to 51% sitting

Lean forward position: higher Qmax and Qavg than sit back posture or knee raising posture
Only 46% of Australian volunteers could squat, so couldn’t test whether this position better
Rane, Ajay (2011) Does posture affect micturition?
PhD thesis, James Cook University.

BOO and storage symptoms (“OAB”)
Pubmed search: “bladder outlet obstruction” and “overactive bladder”
1/50 studies are not about men or rats.

Outlet obstruction
Altered receptor function, myogenic denervation, imbalance of neurotransmitters
Detrusor Overactivity

2 years after Burch or Sling
SISTER trial
Baseline DO on UDS resolved in
19/27 Burch (70%)
10/18 Sling (56%)
New onset DO on UDS
Burch 10/215 (5%)
Sling 18/239 (8%)
New onset urge incontinence
Burch 3%
Sling 3%
Kraus, Lemack et al. Urology 2011
Albo, Richter et al. NEJM 2007

Change UDI irritative
Change UDI obstructive
New urge incontinence by
6 weeks
Persistent urge incontinence at 6 weeks
Persistent urgency
12%
14%
Retropubic
-31
-15
0/298
Transobturator
-33
-15
1/299
10%
13%
Richter, Albo et al. NEJM 2010

Sling take-down improves obstruction better than OAB
• 40 women underwent urethrolysis
• 28/34 with obstructive symptoms resolved
• 12/36 with OAB symptoms resolved
– 56% were on antimuscarinics
Starkman…Dmochowski. J Urol 2008

• Describe both voiding and storage symptoms of BOO in women.
– Most bladder symptoms except SUI
• Understand the association between voiding symptoms of BOO and objective findings of BOO.
– Not much
• State the role of urethral dilation in treating BOO in women.
– Don’t do it
• Describe the most optimal time period to intervene in
BOO following mid-urethral sling.
– Early