IDIOPATHIC DETRUSOR OVERACTIVITY GENUINE STRESS INCONTINENCE CHRONIC URINARY RETENTION BENIGN PROSTATIC HYPERPLASIA LUTS symptoms BLADDER OUTFLOW OBSTRUCTION MANAGEMENT OF MEN WITH BENIGN PROSTATIC HYPERPLASIA OR BLADDER OUTFLOW OBSTRUCTION Urethral stricture CAUSES The common causes of urethral stricture are: ● Inflammatory :Secondary to urethritis, Secondary to balanitis xerotica obliterans (BXO) ● Traumatic: Bulbar urethral injury, Pelvic fracture urethral disruption injury ● Iatrogenic: Secondary to urethral instrumentation including catheterisation and transurethral prostatectomy, Secondary to radical prostatectomy, Secondary to radiotherapy for prostate cancer ● Idiopathic Treatment of urethral strictures MBBS Study Material

1. Diseases pertaining to
micturition & treatment
GROUP- 2

2. Micturition
❏ Micturition is the process by which the urinary bladder
empties when it becomes filled.
❏ This involves 2 main steps:
❏ The bladder fills progressively until the tension in its walls
rises above a threshold level
❏ This elicits the second step, which is a nervous reflex
called the micturition reflex that empties the bladder.

3. Diseases pertaining
to Micturition
Acute Neuropathic bladder
❏ Spinal cord injury
❏ Lesions above T10
❏ Damage to sacral centre

4. Diseases pertaining to micturition : spinal cord injury
❏ Immediately after spinal cord injury, ‘spinal shock’ occurs which may
last for days or months. The detrusor cannot contract, the bladder
distends and overflow incontinence occurs.
❏ The patient is incontinent with small amounts of urine passing
involuntarily from the distended bladder.
❏ Clinical management of spinal injury
❏ The bladder should be emptied during spinal shock by
catheterisation
❏ Encourage high fluid intake
❏ Commence intermittent catheterisation
❏ When the patient is stable undertake full urodynamic evaluation

5. Diseases pertaining to micturition : Lesions above T10
❏ Usually leads to an ‘upper motor neuron’ bladder with reflexes
intact but isolated from higher control mechanisms.
❏ bladder contractions are high pressure and ineffective in
producing bladder emptying; the bladder neck is normally open.
❏ Management:
❏ Patients with low pressure bladder: condom drainage, clean,
intermittent, self catheterization
❏ Patients with poor emptying, low bladder capacity and upper
tract dilatation require treatment with endoscopic
sphincterotomy and condom drainage.

6. Diseases pertaining to micturition
❏ Damage to the sacral centre S2, S3, S4 and cauda equina
lesions:
❏ Usually leads to a ‘lower motor neuron’ bladder, also found in
spina bifida (myelodysplasia); the detrusor is acontractile.
❏ Abdominal straining can produce reasonable emptying but the
mainstay is CISC

8. Diseases pertaining
to micturition
❏ Overactive bladder
❏ Genuine Stress incontinence
❏ Chronic urinary retention
❏ Bladder outflow obstruction
❏ BPH
❏ Urethral stricture

9. Diseases pertaining to micturition
❏ The normal bladder will accept approximately 400– 550 mL
when filled at room temperature at a rate of <50 mL/ min.
❏ The pressure increase in the bladder should be less than 15
cmH2O. In addition, phasic pressure increases should not be
seen.
❏ The normal voiding pressure should not exceed 60 cmH2O in
men and about 40 cmH2O in women, with a flow rate of
between 20 mL/s and 25 mL/s

10. Diseases pertaining to micturition
❏ THE OVERACTIVE BLADDER: Phasic increases in pressure
give rise to urgency and urge incontinence. This abnormality
is found in patients with neurogenic bladder dysfunction, such
as in multiple sclerosis (MS) or Parkinson’s disease, or after a
stroke or spinal injury, when it is known as detrusor
hyperreflexia.
❏ About 50% of men with bladder outflow obstruction have
detrusor instability, and in about half of them the instability
resolves after prostatectomy.

11. Diseases pertaining to micturition
❏ Idiopathic detrusor overactivity is common and must be
distinguished from genuine stress incontinence (GSI) in
women before performing bladder neck suspension
procedures.
❏ In children, overactive bladder symptoms must be carefully
investigated and treated with conservative measures before
initiating antimuscarinic therapy (oxybutynin and tolterodine).

12. Diseases pertaining to micturition : IDIOPATHIC DETRUSOR
OVERACTIVITY
❏ Idiopathic detrusor overactivity may be asymptomatic but usually
results in symptoms of frequency, urgency, urge incontinence,
nocturia or nocturnal incontinence (enuresis), depending on the
severity of the instability.

13. Diseases pertaining to micturition
❏ GENUINE STRESS INCONTINENCE: This is defined as
urinary leakage occurring during increased bladder pressure
when this is solely due to increased abdominal pressure and
not to increased true detrusor pressure. It is caused by
sphincter weakness.

14. Diseases pertaining to micturition : GSI
❏ It is usually found in multiparous women with a history of
difficult labour.
❏ It can be found in normal young women who indulge in
competitive trampolining and in patients with epispadias. The
classic symptom is urine loss during coughing, laughing,
sneezing or a sudden change of posture. The symptoms may
change with the menstrual cycle.

15. Diseases pertaining to micturition : GSI
❏ The volume of urine loss can be measured during an exercise
test, which is performed by putting the patient through a
standard set of tests with 300 mL of fluid in the bladder; in GSI
the fluid losses usually range from 10 mL to 50 mL. Urinary
frequency and urgency are often found in such patients
because they try to avoid incontinence by frequent voiding

16. Diseases pertaining to micturition : GSI
❏ Minor-to-moderate stress urinary incontinence can be
controlled by pelvic floor exercises. However, if this fails, surgery
is indicated. Standard operations include open colposuspension
or the use of a minimally invasive approach involving the
insertion of a transvaginal tape (TVT procedure).

17. Diseases pertaining to micturition
❏ CHRONIC URINARY RETENTION: Chronic urinary retention
with overflow incontinence is recognised by a large residual
volume of urine and is usually associated with high pressures
during bladder filling

18. Diseases pertaining to micturition : CHRONIC URINARY
RETENTION
❏ In chronic retention there is no pain. These patients are at risk
of upper tract dilatation because of high intravesical tension –
they require urgent urological referral.
❏ Treatment is to pass a fine urethral catheter (14F – French
gauge is defined as the circumference in millimetres) and
arrange urological management.

20. Diseases pertaining to micturition : BENIGN PROSTATIC
HYPERPLASIA
❏ Aetiology
❏ Hormones
Serum testosterone levels slowly but significantly decrease
with advancing age; however, levels of oestrogenic steroids
are not decreased equally. According to this theory, the
prostate enlarges because of increased oestrogenic effects. It
is likely that the secretion of intermediate peptide growth
factors plays a part in the development of BPH

22. ❏ It is important to realise that the relationship between
anatomical prostatic enlargement, lower urinary tract
symptoms (LUTS) and urodynamic evidence of bladder outflow
obstruction (BOO) is complex.
Diseases pertaining to micturition : BENIGN PROSTATIC
HYPERPLASIA

23. Diseases pertaining to micturition : LUTS symptoms
❏ Voiding:
❏ hesitancy (worsened if the
bladder is very full);
❏ poor flow (unimproved by
straining);
❏ intermittent stream – stops
and starts;
❏ dribbling (including after
micturition);
❏ sensation of poor bladder
emptying;
❏ episodes of near retention
❏ Storage:
❏ frequency;
❏ nocturia;
❏ urgency;
❏ urge incontinence;
❏ nocturnal incontinence
(enuresis)

24. Diseases pertaining to micturition
❏ BLADDER OUTFLOW OBSTRUCTION: Bladder outflow
obstruction is associated with increased voiding pressures,
often in excess of 90 cmH2O, coupled with low urinary flow

25. Diseases pertaining to micturition : BOO
The following conditions can coexist with BOO, leading to difficulty
in diagnosis and in predicting the outcome of treatment:
● idiopathic detrusor overactivity
● neuropathic bladder dysfunction as a result of diabetes, strokes,
Alzheimer’s disease or Parkinson’s disease; degeneration of bladder
smooth muscle giving rise to impaired voiding and detrusor
instability;
● BOO due to BPH

27. Diseases pertaining to micturition : Bladder Outflow
Obstruction
❏ This is a urodynamic concept based on the combination of low
flow rates in the presence of high voiding pressures. It can be
diagnosed definitively only by pressure–flow studies.
❏ Even low measured peak flow rates (<10–12 mL/s) are not
absolutely diagnostic because, in addition to BOO, weak detrusor
contractions or low voided volumes (owing to instability) can be
the cause

28. Diseases pertaining to micturition : Bladder Outflow
Obstruction
❏ Urodynamically proven BOO may result from:
❏ BPH;
❏ bladder neck stenosis;
❏ bladder neck hypertrophy;
❏ prostate cancer;
❏ urethral strictures;
❏ functional obstruction due to neuropathic conditions

29. Diseases pertaining to micturition : Bladder Outflow
Obstruction
❏ The effects of bladder outflow obstruction are as follows:
❏ The urinary flow rate decreases
❏ Voiding pressure increases
❏ Urinary retention post voiding

30. Diseases pertaining to micturition
❏ MANAGEMENT OF MEN WITH BENIGN PROSTATIC
HYPERPLASIA OR BLADDER OUTFLOW OBSTRUCTION:
❏ Conservative measures include watchful waiting in conjunction
with fluid restriction and reduction in caffeine intake
❏ Drug therapy is with α-blockers
❏ Interventional measures include transurethral resection of the
prostate, which remains the ‘gold standard’; consider open
prostatectomy for large glands

31. Diseases pertaining to micturition : Urethral stricture
Urethral stricture
CAUSES
The common causes of urethral stricture are:
● Inflammatory :Secondary to urethritis, Secondary to balanitis xerotica obliterans
(BXO)
● Traumatic: Bulbar urethral injury, Pelvic fracture urethral disruption injury
● Iatrogenic: Secondary to urethral instrumentation including catheterisation and
transurethral prostatectomy, Secondary to radical prostatectomy, Secondary to
radiotherapy for prostate cancer
● Idiopathic

33. Diseases pertaining to micturition : Urethral stricture
Diagnosis of urethral stricture
● Suspect the diagnosis of urethral stricture in a young man with poor
urinary stream
● Diagnosis is made either by visualisation (urethroscopy) or
radiologically (by urethrography)
● Urinary infection should be excluded

34. Diseases pertaining to micturition : Urethral stricture
Treatment of urethral strictures
● Newly diagnosed strictures are best treated initially by internal
urethrotomy, with a high short-term success rate and a 50% long-term
success rate
● Intermittent self-dilatation increases the success rate of internal
urethrotomy alone
● Urethroplasty should be considered in traumatic strictures and in
recurrent strictures
● Urethral dilatation should be considered in strictures closely related to the
external sphincter mechanism