Turp incont
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post trans urethral resection of prostate urinary incontinence
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Turp incont
- 1. Post TURP urinary incontinence
- 2. History • 54 yrs Gentleman – Frequency of micturition – Nocturia 5-7/night – Urgency 1 year – poor flow of urine – Prolonged voiding – Recurrent UTI • No urge leak, straining, AUR, haematuria, calculuria • Flow : 12/260/30, normal curve • Not on alpha blocker
- 3. • Underwent TURP elsewhere • Post op – multiple episodes of clot retention • requiring catheterization and bladder wash – Continuous dribbling of urine after catheter removal – Increased urinary incontinence at straining, standing and cough – No normal voiding pattern • Bowel habits and erections normal. • Diabetic and hypertensive on tablets
- 5. Examination • General physical examination was unremarkable. • PA: Bladder not palpable. • External genitalia: leaking urine continuously, Left epididymal cyst of about 2.5x2 cm. Bilateral testes normal. • DRE: Tone was normal with positive BCR , flat prostate • Focal Neurological exam: Normal
- 7. Investigations • Hb : 10.9 gm/dl • TLC: 6700 / cumm • Creatinine : 1.47 mg % • Urine c/s : No growth
- 9. USG KUB
- 10. USG report • No Hydronephrosis • Minimal post void residue
- 13. MCU report • Small capacity bladder with trabeculations. • Widened bladder neck with patulous posterior urethra- post TURP status. • Dilated urethra in its entire extent in pre-void phase with spontaneous micturition after releasing the penile clamp. • Represents sphincteric incompetence .
- 15. CMG
- 16. CMG report • Normal compliance • Multiple small DOAs • After only 80ml of bladder volume, he started leaking, even after slow re filling, he could not hold even 100ml of urine and leaked continuously.
- 17. Management • Cysto EUA: – False passage seen in floor of bulbar urethra – Bladder neck wide open. No appreciable sphincteric activity. – Small capacity bladder approximately 150 ml – Trabeculated thick walled bladder • Anticholinergics • Penile clamp
- 19. Learning Points • Causes • How can it be prevented? • Management
- 20. • Incidence of urinary incontinence 1% for TURP1 • Early incontinence : 30–40% • Late iatrogenic stress incontinence : 0.5% • Pathogenesis:- • Bladder dysfunction • Sphincter Incompetence • Mixed Incontinence 1. Theodorou Ch: Post-prostatectomy incontinence. Eur Urol Update Ser 1994
- 21. Aetiology:- • Early incontinence – urge incontinence due to fossa healing, associated UTI , detrusor instability caused by long-lasting BPH. 2 • Late Incontinence - sphincter incompetence (30%), detrusor instability (20%), mixed incontinence (30%), residual adenoma (5%), bladder neck contracture (5%), and urethral stricture (5%).3 2. Zwergel U. Benignes Prostatahyperplasie-(BPH)-Syndrom. Operative und int erventionelle Therapieoptionen. Urologe A 2001 3.Theodrou et al, European urology.
- 22. Management • Early Incontinence:- • Symptomatic – Time-limited anticholinergic - Toltoridine or Darifenacin – Anti-inflammatory regimens - Diclofenac. • Late incontinence :- If persists > 6 months need evaluation. – Ascending urethrogram, – cystourethroscopy, – Urodynamic evaluation
- 23. Bladder dysfunction: - • Nonsurgical Management - Fluid restriction and - behavioral modification - medications - anticholinergics - Pelvic floor exercises • Neuromodulation • Augmentation cystoplasty 4 • Urinary diversion. 4. Flood et al, j Neurourology 1995
- 24. Sphincter incompetence • Conservative treatment :- – pelvic floor exercise5 – TRUS-biofeedback and electrostimulation • Minimally invasive (urethral bulking agents) • Paraurethral balloons6 • Surgical (artificial urinary sphincter or bulbourethral sling). 5.McDonald et al, 2007 6.Hubner et al, BJU 2005
- 25. Prevention: - • Pre surgical evaluation and treatment of detrusor dysfunction. • Good surgical technique to prevent sphincter injury, stay proximal to verumontanum.
Editor's Notes
- ++ During bladder outflow obstruction, the detrusor muscle presents certain changes , leading to detrusor instability that can persist after prostatectomy for BPH and may cause urge incontinence. +++The presence of at least one intact sphincter mechanism (the proximal or the distal urinary sphincter) is essential and adequate for continence. After TURP or open prostatectomy for BPH, continence will depend entirely on the remaining distal sphincter mechanism, provided that the detrusor is stable and of low compliance. Any damage to the distal sphincter during surgery will lead to sphincteric incontinence.