Bladder outlet obstruction

Inhaled anticholinergics are well tolerated with the most common adverse effect being dry mouth. Occasional metallic taste has also been reported with ipratropium. Other anticholinergic adverse effects include constipation, tachycardia, blurred vision, and precipitation of narrow-angle glaucoma symptoms. Urinary retention could be a problem, especially for those with concurrent bladder outlet obstruction. 

Bladder distention (postrenal bladder outlet obstruction)... 

O The lower urinary tract symptoms and signs of benign prostatic hyperplasia are due to static, dynamic, or detrusor factors. The static factor refers to anatomic obstruction of the bladder neck caused by an enlarged prostate gland. The dynamic factor refers to excessive stimulation of a-adrenergic receptors in the smooth muscle of the prostate, urethra, and bladder neck. The detrusor factor refers to irritability of hypertrophied detrusor muscle as a result of long-standing bladder outlet obstruction. 

Plasma blood urea nitrogen (BUN) and serum creatinine may be increased as a result of long-standing bladder outlet obstruction. 

Intravenous pyelogram (IVP) will show retention of radio-contrast in the bladder if the patient has bladder outlet obstruction due to an enlarged prostate only indicated in patients with recurrent hematuria, recurrent urinary tract infection, renal insufficiency, and urolithiasis... 

Bladder outlet obstruction (e.g., benign or malignant prostatic enlargement or hyperplasia)... 

Zderic SA, Rohrmann D, Gong C et al 1996 The decompensated detrusor II evidence for loss of sarcoplasmic reticulum function after bladder outlet obstruction in the rabbit. J Urol 156 587-592... 

BM bone marrow bowel movement BMT bone marrow transplantation BOO bladder outlet obstruction BP blood pressure BPH benign prostatic h5rpCTtrophy bpm beats p minute BSA body surface area BUN blood urea nitrogen (measure of hydration and kidney function) BW body weight C constipation Ca/Ca calcium CA cancCT... 

All cholinesterase inhibitors should be used with caution in patients with cardiac conduction problems because vagotonic effects can lead to bradycardia. In addition, caution is warranted in patients with comorbid asthma, chronic obstructive pulmonary disease, bladder outlet obstruction, or seizures, as well as in patients at risk for gastrointestinal ulcers or bleeding (Fuller and Sajatovic 2000). 

Symptomatic benign prostatic hyperplasia (BPH) is a common medical problem in older men. As many as 40% of men aged 60 years or older have lower urinary tract symptoms consistent with bladder outlet obstruction. Treatment goals in the vast majority of men are to relieve bothersome symptoms that reduce quality of life. In the U.S., treatment for benign prostatic hyperplasia costs more than 2 billion per year and accounts for 1.7 million physician office visits annually (Ishani et al., 2000). 

McBQnney CD, Gaffey MJ, Gillenwater JY. Bladder outlet obstruction after multiple periurethral polytetrafluoroethylene injections. J Urol 1995 153(1) 149-51. 

Hampel C, Dolber PC, Smith MP, et al. Modulation of bladder ai-adrenergic receptor subtype expression by bladder outlet obstruction. J Urol 2002 167 1513-1521. 

Postrenal renal failure Bladder outlet obstruction Prostatic hypertrophy... 

Bladder distention Bladder outlet obstruction Hepatorenal syndrome Postobstruction renal failure... 

Obstructive symptoms, also known as prostatism or bladder outlet obstruction, result when dynamic and/or static factors reduce bladder emptying. The force of the urinary stream becomes diminished, urinary flow rate decreases, and bladder emptying is incomplete or takes a longer time. Patients report urinary hesitancy and straining and a weak urine stream. Urine dribbles out of their penis, and their bladder always feels full, even after they have voided. Some patients state that they need to press on their bladder to force urine out. In severe cases, patients may go into urinary retention when bladder... 

Objective measures of bladder emptying include peak and average urinary flow rate (normal is at least 10 to 15 mL/s). This is determined using a uroflowmeter, which literally checks the rate of urine flow out of the bladder. This is a quick noninvasive outpatient procedure in which the patient s urinary flow is clocked during voiding. A low urinary flow rate implies failure of bladder emptying, but the degree of bladder outlet obstruction correlates poorly with peak urinary flow rate. 

Most patients with overactive bladder and UUI have no identifiable underlying etiology. In fact, the most common cause of bladder overactivity and UUI is idiopathic. Clearly identifiable risk factors for UUI include normal aging, neurologic disease (including stroke, Parkinson s disease, multiple sclerosis, and spinal cord injury), and bladder outlet obstruction (e.g., due to benign prostatic hyperplasia [BPH] or prostate cancer). 

Levin RM, Monson FC, Haugaard N, Buttyan R, Hudson A, Roelofs M, Sartore S, Wein AJ (1995) Genetic and cellular characteristics of bladder outlet obstruction. Urol Clin North Am 22 263-283... 

Some patients have characteristics that dictate compelling indications for certain drugs or combinations. Patients with hypertension and ischemic heart disease, diabetic nephropathy, or cardiac failure may benefit from combinations of drug classes that target both diseases. As hypertension is more common as patients get older, there are often multiple co-morbidities that influence the treatment options. In elderly men hypertension may co-exist with prostate disease, the latter being associated with a variety of lower urinary tract symptoms related to an overactive bladder and/or bladder outlet obstruction. Calcium channel blockers may have beneficial effects on the overactive bladder by reducing detrusor muscle tone, and this has been investigated in a trial of amlodipine plus terazosin compared with terazosin alone in men with mild to moderate hypertension and lower urinary tract symptoms [5 ]. Combination treatment was associated with notable improvement in overactive bladder symptoms and better control of hypertension. 

In the nineteenth and early twentieth centuries, men with chronic bladder outlet obstruction commonly self-catheterized with tubes they carried in hatbands, umbrella handles, and hollow walking sticks. 

Abnormal duplex kidneys used to be and are still detected during the work-up of urinary tract infection or urinary dribbling in girls. They are more and more often demonstrated during fetal life. In utero, it is possible to differentiate between the two collecting systems particularly if one is dilated. It is even possible to differentiate between ectopic ureter and ucele in utero (Joseph et al. 1989 Avni et al. 1991 Abuhamad et al. 1996 Vergani et al. 1999 Caione et al. 1989 Jee et al. 1993). Other forms of presentation include interlabial mass in girls or bladder outlet obstruction. Both conditions are related to urethral prolapse of the ucele (Nussbaum 1983). 

Transient megacystis may he a sign of obstruction and/or vesicoureteric reflux. In boys, it could be the consequence of transient bladder outlet obstruction and the starting point of a series of abnormalities. Notably, it could explain the male predominance in neonatal vesicoureteric reflux. This hypothesis was... 

The clinical presentation is completely different in older children. The main complaint is usually dys-uria or infection (Fig. 6.6). Megacystis and thickening of the bladder wall are less frequent. Kidneys are usually normal, as is renal function. The differential diagnosis should include the other causes of bladder outlet obstruction (see below) and functional disorders such as dysfunctional voiding with severe bladder-sphincter dyscoordination. Both VCU and urodynamic studies can be diagnostic (Fig. 6.7). In case of valves, there is reduced urinary flow with no reinforcement of the perineal electric activity. 

The association of ultrasound, VCU and cystoscopy helps establish a proper differential diagnosis among the causes of congenital or acquired bladder outlet obstruction. 

---