Case 1: A 70-year-old male with a history of Diabetes mellitus (DM) for 10 years, who presents with recurrent urinary retention, necessitating Foley catheter drainage, after failed three failed trails of void. He had microwave prostate therapy performed 3 months ago and is without known neurologic history. His PSA was 1.6 ng/mL and DRE 45 gm, benign. On cystoscopy, there was no stricture or bladder neck contracture seen, with bilobar BPH, and normal bladder. Dr. Gousse then presented a UDS tracing for the experts to interpret.
With the topic of “Treat the Outlet,” Dr. Nitti began by reading the UDS tracing, describing that the patient has a Pdet max of 26 cm H20, with minimal flow, and abdominal straining. He then discussed the use of the ICS nomogram; you are unable to diagnose obstruction definitively with low voiding pressures, as in the patient from the case. Dr. Nitti stated we are not sure the cause of this patient’s bladder dysfunction. Longtime obstruction can affect contractility; this patient may be obstructed even though we are unable to diagnose it on UDS. Treat the outlet first, when an obstruction is likely the cause of DU, but only if the patient is willing to accept possible complications of treating the outlet, knowing a successful outcome is uncertain. In this patient, Dr. Nitti advocates for decompression and retest.
Dr. Bales had the stance to, “Treat the Bladder.” In his view, treating the bladder or outlet are not mutually exclusive; in challenging cases such as this, both can be treated and results maximized. Dr. Bales states that the UDS tracing demonstrates that the bladder functions; he would treat the outlet and address the bladder separately. He states it is important to review the patient’s history. Some medications can contribute to bladder dysfunction (tricyclic antidepressants, opioids, benzodiazepines), optimize DM control to improve bladder function and treat any constipation. Dr. Bales states bethanechol 50 mg QID is reasonable to try, but there is a risk for side effects. If bladder function does not return, he recommends CIC, to avoid chronic indwelling catheterization.
Case 2: A 50-year-old male presents with recurrent UTIs, reports 3 in the past 6 months. His AUA-IPSS score is 20, PSA 0.9 ng/mL, and DRE 25 gm. His PVR in clinic is 375 ml, and is currently on both an alpha-blocker and 5-alpha-reductase inhibitor. Of note, he gives a history of a back injury in the past but has had a neurology evaluation with an MRI, negative for pathology.
Dr. Bales began the discussion by interpreting the UDS tracing, which demonstrates the bladder is not functioning and suggests a contractility. He recommends placing the patient on prophylactic antibiotic to prevent recurrent infections. He may necessitate clean intermittent catheterization, even if just once daily. He also recommends calculating his percentage post void residual to total bladder capacity.
Dr. Nitti then addressed the UDS tracing; the patient voided with abdominal straining, without sufficient bladder contraction. At this time, he has very low suspicion for bladder outlet obstruction, therefore, he has a low suspicion of success after an outlet procedure in this patient, i.e. a bladder neck incision. He states it is very important to manage expectations in these patients and should have a goal of controlling UTI’s.
Presented by: Victor W. Nitti, MD and Gregory T. Bales, MD
Moderated by: Angelo E. Gousse, MD
Written by: Cristina Palmer, DO, Female Urology, Pelvic Reconstruction, Voiding Dysfunction Fellow, Department of Urology, UC Irvine Medical Center, Orange, California at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting (SUFU 2018), February 27-March 3, 2018, Austin, Texas