Jerry G. Blaivas

Bladder Outlet Obstruction versus Impaired Detrusor Contractility: The Role of Uroflow

The uroflow curves of 45 men with either bladder outlet obstruction or impaired detrusor contractility were retrospectively reviewed. The definitive diagnoses were attained by clinical and video-urodynamic studies with simultaneous detrusor pressure and uroflow measurements. Eight parameters were analyzed to determine if uroflow can differentiate obstruction from impaired contractility. There were no differences between the 2 groups in any of the parameters. This finding suggests that uroflowmetry as a single examination cannot distinguish between bladder outlet obstruction and impaired detrusor contractility.

Urodynamic Findings in Parkinson’s Disease

Neurological evaluation was performed in 24 men and 5 women with Parkinsons disease who had persistent bladder symptoms. Detrusor hyperreflexia was found in 26 (90 per cent) of the patients. Sporadic involuntary electromyography activity of the external sphincter during involuntary detrusor contractions was encountered in 61 per cent but in none did this cause obstruction. Coordinated striated sphincter relaxation during voluntary detrusor contraction was found in 13 patients (45 per cent). Among 22 men who were in the prostatic disease age group only 4 (18 per cent) had definite prostatic obstruction. Moreover, none of 8 men with persistent symptoms after prostatectomy had evidence of bladder outlet obstruction.

Bladder Neck Obstruction in Women

Bladder neck obstruction in women is rare. The symptoms are confounding and nonspecific. The diagnosis depends on demonstrating poor uroflow, a detrusor contraction of adequate magnitude and duration, and radiographic evidence of obstruction at the vesical neck. We treated successfully 3 women with vesical neck obstruction by transurethral vesical neck incision.

Detrusor-External Sphincter Dyssynergia in Men with Multiple Sclerosis: An Omjnous Urologic Condition

A total of 27 men with multiple sclerosis underwent urodynamic evaluation as part of a prospective study of voiding dysfunction. Of 18 patients with detrusor-external sphincter dyssynergia 9 suffered serious urologic complications, including repeated episodes of urosepsis, vesicoureteral reflux and urolithiasis. None of the 9 patients without dyssynergia suffered any urologic complications. Urologic complications were correlated highly to the presence of detrusor-external sphincter dyssynergia and the severity of multiple sclerosis but not to duration of multiple sclerosis, age of the patient or type of dyssynergia. Although no treatment was without complications it appears that either anticholinergics plus intermittent self-catheterization or condom catheter drainage is superior to an indwelling catheter for initial conservative treatment. External sphincterotomy or urinary diversion may be necessary if conservative therapy fails.

Persistence or recurrence of symptoms after transurethral resection of the prostate: a urodynamic assessment.

Approximately 15 to 20% of patients who undergo transurethral resection of the prostate for benign prostatic hyperplasia have persistent or recurrent voiding symptoms requiring further therapy. To elucidate the etiology of these voiding abnormalities, the urodynamic findings of 129 consecutive men (mean age 72 years) with post-transurethral resection voiding symptoms were retrospectively analyzed with respect to symptoms, uroflowmetry and synchronous video pressure-flow cystometry. Our findings revealed obstruction in 38% of the patients, impaired contractility in 25% and intrinsic sphincter deficiency in 8%. Among 80 patients without neurological disorders involuntary bladder contractions were detected in 50%. However, in 49 patients with neurological disorders involuntary bladder contractions were detected in 76%. This difference was statistically significant. There were 15 patients who failed 2 or more transurethral resections of the prostate, and involuntary bladder contractions were detected in 80%, obstruction in 27%, impaired contractility in 27% and sphincteric incontinence in 20%. Our study reveals residual or recurrent obstruction to be a contributing factor in less than half of all patients who fail transurethral resection of the prostate. Furthermore, patients with a concomitant neurological disorder and those who have undergone more than 1 transurethral resection of the prostate have a significantly higher incidence of involuntary bladder contractions. These results underscore the importance of obtaining complete urodynamic assessment in patients with persistent or recurrent voiding symptoms following transurethral resection of the prostate to guide appropriate therapy.

Unsuspected proximal urethral obstruction in young and middle-aged men

Proximal urethral obstruction, a common cause of prostatism in young and middle-aged men, often is misdiagnosed as prostatitis, neurogenic bladder or a psychogenic voiding disorder. Simple urodynamic studies (uroflowmetry and cystometry) do not distinguish a poor flow owing to bladder neck obstruction from that caused by poor detrusor contractility in these patients. Only the simultaneous measurement of detrusor pressure and uroflowmetry can make this distinction. A total of 23 patients with unsuspected proximal urethral obstruction underwent synchronous video-pressure-flow electromyography studies, and were treated and followed for a minimum of 1 year. Treatment by transurethral prostatic resection or bladder neck incision almost always was curative but alpha-adrenoceptor blocking agents have not been effective. All patients who underwent transurethral prostatic resection or bladder neck incision at the 5 and 7 oclock positions have had retrograde ejaculation but both patients who underwent unilateral bladder neck incision reported antegrade ejaculation.

Atlas of Urodynamics

Section One - Patient evaluation. Overview. Pre-urodynamic evaluation. Section Two - Techniques. Cystometry. Leak Point Pressure. Uroflowmetry. Electromyography. Urethral pressure measurement. Synchronous pressure/uroflow. Video-urodynamics. Sphincter electromyography. Section Three - Diagnosis. A Neuro-urology. Normal and abnormal physiology of micturition. Spinal cord injury. Cerebrovascular accident, Parkinsons Disease and other intracranial diseases. Multiple sclerosis and other demyelinating disorders. Diabetes Mellitus. Cauda equina, Infections and other spinal diseases. B Male voiding disorders. BPH, bladder neck obstruction and prostatitis. Post-prostatectomy incontinence. C Female Urology. Stress incontinence. Mixed incontinence. Overactive bladder. Bladder outlet obstruction. Pelvic organ prolapse. Leak point pressure in stress incontinence. Painful bladder syndrome and interstitial cystitis. D Pediatrics, geriatrics and bladder reconstruction. Pediatric urodynamics. Geriatric urodynamics. Urodynamic evaluation of urinary tract reconstruction. Appendix. ICS recommendations on good urodynamic practice

Neurologic Implications of the Pathologically Open Bladder Neck

Normally the bladder neck remains closed except during voiding. We reviewed 550 consecutive patients who underwent synchronous video/flow/pressure/electromyography studies to identify whether neurologic factors are involved in the pathogenesis of an abnormally open bladder neck. A total of 33 patients who had not undergone prior bladder neck surgery had an open bladder neck at rest. The prevalence of neurologic lesions in patients with an open bladder neck was significantly greater than in those with a normal bladder neck. However, there was no correlation between any specific lesion and the incidence of an open bladder neck. Patients with myelodysplasia had an inordinately high incidence of open bladder neck. We conclude that abnormalities of bladder neck innervation may result in a pathologically open bladder neck.

The cholinergic and purinergic components of detrusor contractility in a whole rabbit bladder model

Whole rabbit bladders were suspended in a bath chamber and stimulated with ATP, bethanechol, electrical field stimulation, and bethanechol + ATP. Detrusor pressure and fluid expelled by the bladder were recorded, synchronized, and digitized. Detrusor work and power were calculated with a computer program. Maximum work was 61.4 +/- 28.7, 83.3 +/- 17.0, 85.0 +/- 15.0, 90.8 +/- 13.1 cm. H2O, ml. for ATP, bethanechol, electrical and bethanechol + ATP, respectively. Maximum power generated by ATP was 4.8 +/- 3.0 cm. H2O, ml./sec and was approximately 66% of that generated by bethanechol, and 50% of that generated by electrical stimulation, and bethanechol + ATP. ATP cannot empty the bladder with moderate outlet resistance while bethanechol and electrical stimulation can. Our results suggest that ATP is able to generate detrusor power and achieve work in bladder emptying. However, ATP generated power and work is considerably less than that of electrical stimulation or bethanechol alone. ATP mediated contraction is not inhibited by atropine or tetrodotoxin but is inhibited by P2 purinoceptor desensitization, suggesting a functional role of purine receptors on detrusor smooth muscle. Since ATP generated pressure is more rapid than with bethanechol alone, we support the hypothesis that ATP may be important in the initiation of micturition.

Critical Evaluation of the Crede Maneuver: A Urodynamic Study of 207 Patients

The efficacy of Credés maneuver to promote voiding was evaluated prospectively in 207 patients with a variety of lower urinary tract disorders. The normal response to Credés maneuver was a contraction of the external urethral sphincter (the Credé effect), an increase in urethral pressure and maintained closure of the vesical neck. Relaxation of the external urethral sphincter and synchronous opening of the bladder neck during Credés maneuver were seen in only 4 patients (2 per cent). We conclude that Credés maneuver is an inefficient method of bladder emptying in the majority of patients and even when voiding is accomplished with Credés maneuver it usually is grossly inefficient and associated with significant urethral obstruction.