evaluation of lower urinary tract symptoms (luts) jerry g. blaivas, md clinical professor of urology...
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Evaluation of Lower Urinary Tract Symptoms (LUTS)
Jerry G. Blaivas, MD
Clinical Professor of Urology
Weil-Cornell College of Medicine
Adjunct Professor of Urology
SUNY Downstate Medical Center
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Lower Urinary Tract Symptoms (LUTS)
• Storage symptoms(irritative symptoms)
• Voiding symptoms (obstructive symptoms)
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Storage Voiding
Frequency
Urgency
Incontinence
Nocturia
Pain
Weak stream
Hesitancy
Incomplete emptying
Urinary retention
Post void dribblingStorage & voiding sx may be due to the bladder, the outlet or both bladder and outlet
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Storage SymptomsBecause of the Bladder
• Detrusor overactivity- Idiopathic- Non-neurogenic
(pathologic)- Neurogenic
• Low bladder compliance
• Sensory urge
• Fistula
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Storage SymptomsBecause of the Sphincter
• Functional classification
• Urethral hypermobility• Intrinsic sphincter deficiency
• Anatomic classification
• Type 0 - 3 SUI
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Voiding SymptomsBecause of the Bladder
• Impaired detrusor contractility
neurogenic
myogenic
acquired behavior
• Detrusor overactivity
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Emptying Problems Because of the Outlet
• Anatomic:
• prolapse
• prior surgery
• urethral diverticulum
• urethral stricture
• primary bladder neck
• Functional
• dyssynergia
• acquired behavior
• primary bladder neck
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Diagnostic Evaluation: Goals
• Define underlying
pathophysiology
• Assess risk factors & co-
morbidities
• Identify remediable
conditions
• Formulate treatment plan
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Underlying Pathophysiology
• Detrusor overactivity• Sensory urgency • Urethral obstruction• Sphincter dysfunction • Impaired detrusor contractility• Fistula• Polyuria
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Identify Risk Factors
• Detrusor sphincter dyssynergia
• Low bladder compliance
• Significant urethral obstruction
• Grade 3 – 4 POP
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Evaluation
• History & physical exam
• Questionnaire
• Urinalysis & culture
• Bladder diary
• Post void residual urine (PVR)
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Evaluation (cont’d)
• Uroflow (Q)
• Pad test
• Cystoscopy
• Urodynamics
• Urinary tract imaging
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Imaging
• Urinary Tract – Renal Ultrasound
– CT scan
– MRI
– Cystogram & VCUG
• Pelvis– Ultrasound:
• Vaginal
• Perineal
• Abdominal
– CT scan
– MRI
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CYSTOGRAM & VCUG
• Cystogram - Radiographjc imaging ofof the bladder during filling
• VCUG (Voiding cysto-urethrogram) - Radiographic imaging of the bladderand urethra during voiding
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CYSTOGRAM & VCUG
• Integrity of the sphincter
• Type & degree of urethral mobility
• Site of obstruction (narrowest partof the urethra during voiding)
• Vesico-ureteral reflux
• Bladder & urethral diverticula
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Indications for Imaging*
• hematuria• neurogenic bladder• significant post-void residual• flank, abdominal or pelvic pain• untreated grade 3 – 4 POP• extra-urethral incontinence• low bladder compliance
*4th ICI, 2008 (and me)
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History
• Questionnaire
• Patient interview
• Each symptom assessed by:• frequency of occurrence• severity• how bothersome
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History
• Prior Rx
• Medications
• Review of systems
• Previous surgery
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Physical Examination• General
• Neurologic
• Uro - gynecologic
• Neuro - urologic perianal sensation anal sphincter tone anal sphincter control b–c reflex
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Bladder Diary
• Essential component of the w/u
• Time & amount of each urination
• Description of symptoms
• +/- Oral intake
• The diary is a snapshot to be
compared to day to day sx
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Variable
Mean /MedianDay-time volume (ml) 1261 (721)
Night-time volume (ml) 468 (414)
Frequency Day 6.7 (6.5)
Frequency Night 0.4 (0.3)
Bladder Capacity day 229 (220)
Bladder capacity night 332 (294)
24hr Volume 1729 (1619)
24hr Frequency 7.1 (6.8)
Minimum void volume 81 (47)
Maximum void volume 514 (190)
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Why did you urinate? (0) Out of convenience (no urge or desire) (1) Mild urge (but can delay urination for an hr) (2) Moderate urge (can delay > 10 but <60 min) (3) Severe urge (can delay for < 10 min)
(4) Desperate urge (must go immediately) Incontinence grade: Grade 1 - some drops Grade 2 - moderate loss (wet underpants) Grade 3 - extensive loss (wet outer clothes)
Why did you urinate? (0) Out of convenience (no urge or desire) (1) Mild urge (but can delay urination for an hr) (2) Moderate urge (can delay > 10 but <60 min) (3) Severe urge (can delay for < 10 min)
(4) Desperate urge (must go immediately) Incontinence grade: Grade 1 - some drops Grade 2 - moderate loss (wet underpants) Grade 3 - extensive loss (wet outer clothes)
OAB Bladder Diary Instructions
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Time UPS Volume (ml) Incontinence Grade
6 AM 4 120 1
7:30 3 90 0
8:00 4 90 1
9:10 3 90 0
12:30 2 120 0
5:50 1 90 0
8:00 2 60 0
10:00 2 30 0
12:00 4 100 1
3:00 4 100 2
8:40 2 60 0
6:00 4 120 1
OAB Diary
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Pad Test
• Useful for quantifying the amount of urine loss – two kinds:
• Stress pad test (20 min – 1 hour)(to provoke incontinence)
• 24 hour – 3 day – 7 day pad test( to mimic typical day)
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24 Hour Pad Test
• Patient changes pads PRN
• Put each pad in plastic bag
• Bring pads to next office visit
• Weigh pads (1 gm = 1 ml urine loss)
• normal < 8 gms/24 hours
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Post Void Residual Urine
• Assessment of emptying efficiency
• Measured by ultrasound or catheter (when there is a need for catheterization)
• Results may prompt further study
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• An elevated PVR only means that the bladder did not contract strongly enough for that urethra during that particular micturition
• It does not necessarily mean there is bladder outlet obstruction
Post Void Residual Urine
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Post Void Residual Urine
• A low PVR does not exclude urethralobstruction
• PVR has very larger intra-individual variability
• PVR should be repeated many times before clinical judgments are made
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Uroflow (Q)
• Functional evaluation of interactionbetween the bladder & urethra
• Low flow:bladder outlet obstructionimpaired detrusor contractility
• Evaluate Qmax, Qave & shape of curve
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ml/S
20
10
UroflowNormal
Seconds
ObstructedImpaired contractilityAcquired voiding dysfunction
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Indications for Q & PVR*
• Voiding symptoms
• Elevated PVR
• Results may prompt further
investigation
• I get Q & PVR in all patients
*4th ICI, 2008
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Indications for Cystoscopy*
• hematuria
• sterile pyuria
• pelvic/bladder/urethral pain
• vesicovaginal fistula
• extra-urethral incontinence
4th ICI, 2008
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Purpose of Urodynamics
• Reproduce symptoms
• Diagnose pathophysiology of underlying symptoms
• Identify risk factors
• Direct treatment
• Prognosticate
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Risk Factors
• Detrusor sphincter dyssynergia
• Low bladder compliance
• Significant urethral obstruction
• Grade 3 – 4 POP
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Basic Urodynamics
• Cystometry
• Leak point pressure
• Uroflow
• PVR
• Cystogram & VCUG
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Advanced Urodynamics• Synchronous Pdet/Q
• Sphincter EMG
• Dynamic & micturitional UPP
• Videourodynamics
• Computer indices of detrusorcontractility & urethral obstruction
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Urodynamics
• An interactive test between patient & physician
• The findings must be interpreted at the time of the study
• It is not possible to interpret the study by looking at the tracings afterwardsunless there has been a detailed annotation
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Prior to Urodynamics
• What are the symptoms?
• Functional bladder capacity
• Uroflow
• Postvoid residual urine
• Neurologic lesion?
• Formulate questions to be
answered by the study
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Indications for Urodynamics
• Low uroflow
• High PVR
• Uncertain diagnosis
• Finding that requires further evaluation
• Persistent symptoms despite apparently appropriate treatment
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Indications for Urodynamics
• Empiric treatment associated with risk • Irreversible or potentially morbid
treatment is planned• Risk of renal or bladder damage from
pre-existing conditions (radiation, NGB)• Harmful sequelae can occur in the absence
of symptoms
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Storage Phase Urodynamics
• Cystometrogram (CMG)
• Leak Point Pressure
• Urethral Pressure Measurements
• EMG
• Cystogram
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Emptying Phase Urodynamics
• Detrusor pressure – uroflow study
• Micturitional urethral pressure profile
• Sphincter electromyography (EMG)
• Post void residual
• Voiding cystourethrogram
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Cystometry (CMG)
• Measurement of bladder pressure and volume bladder filling; records:
• Bladder sensations
• Bladder pressure
• Involuntary bladder contractions
• Bladder compliance
• Bladder capacity
• Control over micturition
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Idealized CMG
pdet
Volume
Storage Voiding
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• Gravity filling• Talk to patient• Observe height of water column• Account for every rise in pressure:
• detrusor contraction• increase in abdominal pressure• low compliance
• Observe for incontinence
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Caveats
• CMG only assesses the bladder’s response to filling
• Many CMG abnormalities are caused by voiding dysfunction
• If CMG alone is done, underlying problem may be missed
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(Voiding) Detrusor PressureUroflow Study
• Urethral obstruction = high detrusor pressure & low uroflow
• Impaired detrusor contractility = low or poorly sustained detrusor pressure& low flow
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Urethral Obstruction
• Normal or high voiding pressure• Decreased uroflow
Qmax < 12 mL.S
pdet@Qmax > 20 cm H20
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Blaivas - Groutz Nomogram
0
20
40
60
80
100
120
140
160
0 10 20 30 40 50Free Qmax (ml/ sec)
pdet
.max
(cm
H2O
)
Moderate obstruction (2)
Severe obstruction (3)
Mild obstruction (1)
Unobstructed (0)
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Impaired Detrusor Contractility
• Decreased voiding pressure• Decreased uroflow
Qmax < 12 mL.S
pdet@Qmax < 20 cm H20
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2Strss
High pressure
Low flow
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JK
Low pressure
Low flow
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Videourodynamics• Combines urodynamics with fluoroscopic imaging
of the LUT during
–bladder filling
–provocative maneuvers
–voiding
• Most accurate means of assessment
• Each parameter serves as a check against the others
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Evaluation of Stress Incontinence
• HX, PE (observation of SUI, prolapse)
• UA
• Q-tip test
• Bladder diary (incontinence episodes)
• Q & PVR (straining pattern)
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Conditions Causing Incontinence
• Bladder problems Detrusor overactivity Low bladder compliance Fistula
• Sphincter problems Urethral hypermobility Intrinsic sphincter deficiency
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Q-tip test
• Place lubricated Q-tip into meatus
• Record resting angle
• Record maximum deflection during cough and strain
• Hypermobility > 30O deflection
A measure of urethral mobility
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Q-tip Test
> 30O = hypermobility
Cough or strain
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50O
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Vesical Leak Point Pressure(VLPP)
• The bladder is filled with 150 ml • The patient coughs or strains• VLPP = Pves at leakage• Low VLPP = intrinsic sphincter
deficiency• A means of quantitating intrinsic
sphincter strength
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RwnNo leak
Cough
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Rwn
VLPP
leak
Cough
VLLP = 45 cm H20Qtip = 0 > 10O
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VLPP
AGAGAG
VLLP = 92 cm H20Qtip = 0 > 60O
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AG
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Urethral Hypermobility vs ISDFleischmann et al J Urol 169:999, 2003
• No correlation of ALPP with hypermobility:
–ALPP < 60 24% hypermobile
–ALPP 60-90 31% hypermobile
–ALPP > 90 41% hypermobile
Fleischmann et al, J. Urol 169(3): 999-1002, 2003
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Urethral Hypermobility vs ISDFleischmann et al J Urol 169:999, 2003
• LPP & mobility do not correlate with incontinence episodes or pad weight
• ISD and hypermobility do not define discrete classes of patient
• Use LPP & mobility parameters to characterize not classify
Fleischmann et al, J. Urol 169(3): 999-1002, 2003.
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Evaluation of OAB
• HX, PE (prolapse, urethral tic, NGB, UTI, bladder cancer)
• UA
• Bladder diary (voiding frequency, urge voids, maximum voided volume)
• Q & PVR (urethral obstruction, impaired contractility retention)
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Urodynamic Evaluation of OAB
• Etiology
–detrusor overactivity
–sensory urgency
• Classification (based on control
mechanisms)
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Detrusor Overactivity (DO)
• Idiopathic (detrusor instability)
• Pathologic (detrusor instability)
• Neurologic (NDO, detrusor
hyperreflexia)
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Idiopathic Detrusor Overactivity
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BA
Involuntary Contraction
Trying to hold
incontinent
Can’t hold any longer
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Pathologic DO
• Urinary tract infection
• Genital prolapse
• Sphincteric incontinence
• Urethral obstruction
• Bladder cancer
• Bladder stones
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Pathologic Detrusor Overactivity
Grade 3 prolapse
Grade 1 urethral obstruction
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FK
Involuntary detrusor contraction
Incontinent
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Urethral catheter
Urethral meatus
cystocele
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Pathologic Detrusor Overactivity
Bladder cancer
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Involuntary detrusor contractions
Bladder tumor(filling defects)
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Remediable Causes of DO
• Urinary tract infection
• Urethral obstruction
• Stress incontinence
• Urethral diverticulum
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Remediable Causes of DO
• Foreign body
• Genital prolapse
• Bladder stones
• Bladder cancer
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Sensory Urgency
• An uncomfortable urge to void unassociated with detrusor overactivity
• Synonymous with hypersensitive bladder and painful bladder syndromes
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Sensory Urgency
• Severe urge to void
• Low bladder volume
• Stable bladder
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Sensory UrgencyEtiology
• Urinary tract infection
• Bladder outlet
obstruction
• Idiopathic
• Bladder stones
• Acquired behavior
• Bladder cancer
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Evaluation of NGB
• HX, PE (extent of neurologic deficit, urinary retention, febrile
UTI)
• Urinalysis
• +/- Bladder diary & pad test
• +/- Q & PVR
• Videourodynamics
• +/- upper tract imaging
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Neurogenic DO
• Stroke
• Parkinson's disease
• Multiple sclerosis
• Spina bifida
• Transverse myelopathy– spinal cord injury
– transverse myelitis
– tumor
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Detrusor Hyperreflexia
• Synergy
–Stroke
–Parkinson’s
–MS(supraspinal)
–Spina bifida
• Dyssynergy
–SCI
–MS (spinal)
–Spina bifida
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Involuntary Contraction
Can’t hold any longerPR
No flow
Trying to hold
incontinent
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PS
Involuntary detrusor contraction
Involuntary sphincter contraction
Obstruction due to sphincter contraction
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BLADDER COMPLIANCE• The ratio of a small change in bladder
volume to a small change in detrusor pressure
• bladder vol. = bladder compliance pdet
• A measure of bladder wall "stiffness”
• High filling pressures are more clinically relevant
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Causes of Low Bladder Compliance
• Myelodysplasia
• Thoracolumbar SCI
• Indwelling catheter
• Bladder surgery
• Urethral obstruction
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DS
Steep rise in pressure
Vesico-ureteral reflux
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DS
Stop filling
Involuntary detrusor contraction
Vesico-ureteral reflux
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Detrusor Leak Point Pressure(DLPP)
• Fill bladder until leakage occurs
• DLPP = Pdet at leakage
• For any bladder, the higher the DLLP, the higher the urethral resistance
• Untreated, a high DLPP poses high risk for renal damage
• DLPP is related to bladder compliance & urethral resistance
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DS
DLPP
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2
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Evaluation of Voiding Symptoms
• HX, PE (prolapse, urethral tic, NGB)
• Urinalysis
• Bladder diary
• Q & PVR (urethral obstruction,
impaired contractility, retention)
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• Patient: 51 y/o woman
• History: “pot belly” > plastic surgeon for abdominoplasty > palpable bladder > PVR = 2100 ml
SSTRS
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• Exam: palpable bladder, normal neurologic
• Uroflow: 4 ml/S , interrupted pattern, voided volume = 150 ml
• PVR: 810 ml
• Cystoscopy: 3+ trabeculation, two large bladder diverticula
SSTRS
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2Strss
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• Treatment: Transurethral resection of vesical neck (2 gms)
• Pathology: fibromuscular tissue lined with urothelium with squamous metaplasia
• Uroflow: 31 ml/S , normal pattern, voided volume = 400 ml
• PVR: 95 ml
SSTRS
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50
Flow
0
Ml/S
SSTRS
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SS Post -op