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Bladder Outlet Obstruction in Women: Functional Causes

  • Lower Urinary Tract Symptoms & Voiding Dysfunction (H Goldman and G Badlani, Section Editors)
  • Published:
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Abstract

Bladder outlet obstruction (BOO) in women has received less focus in the past, as compared with BOO in men; however, more recently, studies have further examined BOO and voiding dysfunction in women to define the various etiologies, diagnostic criteria, and treatment strategies. The differential diagnosis in women is broad and includes anatomic, neurologic, and functional etiologies. This review focuses on the functional etiologies, including dysfunctional voiding, Fowler’s syndrome, and primary bladder neck obstruction in adult women.

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References

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  1. Haylen B, Ridder D, Freeman R, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Floor Dysfunction. Neurourol Urodyn. 2010;29:4–20.

    PubMed  Google Scholar 

  2. Tanagho E, Miller E, Meyers F, Corbett R. Observations on the dynamics of the bladder neck. BJU Int. 1966;38:72–84. Important early work on normal micturition.

    Article  CAS  Google Scholar 

  3. Tanagho E, Miller E. Initiation of voiding. BJU Int. 1970;42:175–83. Important early work on normal micturition.

    Article  CAS  Google Scholar 

  4. Nager C, Albo M, Fitzgerald M, McDermott S, Wruck L, Kraus S, et al. Reference urodynamic values for stress incontinent women. Neurourol Urodyn. 2007;26:333–40.

    Article  CAS  PubMed  Google Scholar 

  5. Defreitas G, Zimmern P, Lemack G, Shariat S. Refining diagnosis of anatomic female bladder outlet obstruction: comparison of pressure flow study parameters in clinically obstructed women with those of normal controls. Urology. 2004;64:675.

    Article  PubMed  Google Scholar 

  6. Chassange S, Bernier P, Haab F, Roehrborn C, Reisch J, Zimmern P. Proposed cutoff values to define bladder outlet obstruction in women. Urology. 1998;51:408.

    Article  Google Scholar 

  7. Lemack G, Zimmern P. Pressure flow analysis may aid in identifying women with outflow obstruction. J Urol. 2000;163:1823.

    Article  CAS  PubMed  Google Scholar 

  8. Blaivas J, Groutz A. Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology. Neurourol Urodyn. 2000;19:553.

    Article  CAS  PubMed  Google Scholar 

  9. Nitti V, Tu L, Gitlin J. Diagnosing bladder outlet obstruction in women. J Urol. 1999;161:1535.

    Article  CAS  PubMed  Google Scholar 

  10. Akikwala T, Fleischman N, Nitti V. Comparison of diagnostic criteria for female bladder outlet obstruction. J Urol. 2006;176:2093–7. Useful in analyzing parameters of bladder outlet obstruction in women.

    Article  PubMed  Google Scholar 

  11. Hinman F, Baumann F. Vesical and ureteral damage from voiding dysfunction in boys without neurologic or obstructive disease. J Urol. 1973;109:727–32. Original paper describing Hinman’s syndrome.

    CAS  PubMed  Google Scholar 

  12. Allen T, Bright T. Urodynamic patterns in children with dysfunctional voiding problems. J Urol. 1978;119:247–9. Original description of dysfunctional voiding.

    CAS  PubMed  Google Scholar 

  13. Raz S, Smith R. External sphincter spasticity syndrome in female patients. J Urol. 1976;115:443–6.

    CAS  PubMed  Google Scholar 

  14. Minassian V, Lovatsis D, Pascali D, Alarab M, Drutz H. Effect of childhood dysfunctional voiding on urinary incontinence in adult women. Obstet Gynecol. 2006;107:1247–51.

    Article  PubMed  Google Scholar 

  15. Groutz A, Blaivas J, Pies C, Sassone A. Learned voiding dysfunction (non-neurogenic neurogenic bladder) among adults. Neurourol Urodyn. 2001;20:259–68.

    Article  CAS  PubMed  Google Scholar 

  16. Fan Y, Lin A, Wu H, Hong C, Chen K. Psychological profile of female patients with dysfunctional voiding. Urology. 2008;71:625–9.

    Article  PubMed  Google Scholar 

  17. Bellina J, Schenck D, Millet A, Denicola C, Kelly R, Cook A. Outflow uropathy: occupational disorder? J La State Med Soc. 1999;151:414–9.

    CAS  PubMed  Google Scholar 

  18. McGuire E, Savastano J. Urodynamic studies in enuresis and the nonneurogenic neurogenic bladder. J Urol. 1984;132:299.

    CAS  PubMed  Google Scholar 

  19. Xu D, Qu C, Ren J, Jiang H, Yao Y, Min Z, et al. Impact of tension free vaginal tape procedure on dysfunctional voiding in women with stress urinary incontinence. Int J Urol. 2010;17:346–52.

    PubMed  Google Scholar 

  20. Carlson K, Rome S, Nitti V. Dysfunctional voiding in women. J Urol. 2001;165:143–8.

    Article  CAS  PubMed  Google Scholar 

  21. Chen Y, Kuo H. Clinical and video urodynamic characteristics of adult women with dysfunctional voiding. J Formos Med Assoc. 2014;113:161–5.

    Article  PubMed  Google Scholar 

  22. Van Nieuwkoop C, Voorham-van der Zam P, Van Laar A, et al. Pelvic floor dysfunction is not a risk factor for febrile urinary tract infection in adults. BJU Int. 2010;105:1689–95.

    Article  PubMed  Google Scholar 

  23. Minardi D, D’Anzeo G, Parri G, Polito M, Piergallina M, Asmar Z, et al. The role of uroflowmetry biofeedback and biofeedback training of the pelvic floor muscles in the treatment of recurrent urinary tract infections in women with dysfunctional voiding: a randomized controlled prospective study. Urology. 2010;75:1299–304.

    Article  PubMed  Google Scholar 

  24. Mabry E, Carson C, Older R. Evaluation of women with chronic voiding discomfort. Urology. 1998;18:244.

    Article  Google Scholar 

  25. Tanagho E, Miller E, Lyon R, Fisher R. Spastic striated external sphincter and urinary tract infection in girls. BJU Int. 1971;43:69–82.

    Article  CAS  Google Scholar 

  26. Deindl F, Vodusek D, Bischoff C, Hofmann R, Hartung R. Dysfunctional voiding in women: which muscles are responsible? B J Urol. 1998;82:814–9. Important in diagnosis of dysfunctional voiding.

    CAS  Google Scholar 

  27. Minardi D, Parri G, D’Anzeo G, Fabiani A, Asmar Z, Muzzonigro G. Perineal ultrasound evaluation of dysfunctional voiding in women with recurrent urinary tract infection. J Urol. 2008;179:947–51.

    Article  PubMed  Google Scholar 

  28. Rogalski M, Kellogg-Spadt S, Hoffmann A, Fariello J, Whitmore K. Retrospective chart review of vaginal diazepam suppository use in high-tone pelvic floor dysfunction. Int Urogynecol J. 2010;21:895–9.

    Article  PubMed  Google Scholar 

  29. Xu D, Chuangyu Q, Meng H, Ren J, Zhu Y, Min Z, et al. Dysfunctional voiding confirmed by transdermal perineal electromyography, and its effective treatment with baclofen in women with lower urinary tract symptoms: a randomized double-blind placebo-controlled crossover trial. BJU Int. 2007;100:588–92. Well-designed trial looking at the effect of baclofen on dysfunctional voiding.

    Article  CAS  PubMed  Google Scholar 

  30. Phelan M, Franks M, Somogyi G, Yokoyama T, Fraser M, Lavelle J, et al. Botulinum toxin urethral sphincter injection to restore bladder emptying in men and women with voiding dysfunction. J Urol. 2001;165:1107–10.

    Article  CAS  PubMed  Google Scholar 

  31. Roth T, Vandersteen D, Hollatz P, Inman B, Reinberg Y. Sacral neuromodulation for the dysfunctional elimination syndrome: a single center experience with 20 children. J Urol. 2008;180:306–11.

    Article  PubMed  Google Scholar 

  32. Fowler C et al. Abnormal electromyographic activity of the urethral sphincter, voiding dysfunction, and polycystic ovaries: a new syndrome? BMJ. 1988;297:1436–8. Original paper describing Fowler’s syndrome.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  33. Osman N, Chapple C. Fowler’s syndrome—a cause of unexplained urinary retention in young women? Nat Rev Urol. 2014;11:87–98.

    Article  PubMed  Google Scholar 

  34. Amarenco G, Raibaut P, Ismael S, Rene-Corail P, Haab F. Evidence of occult dysautonomia in Fowler’s syndrome: alteration of cardiovascular autonomic function tests in female patients presenting with urinary retention. BJU Int. 2006;97:288–91.

    Article  PubMed  Google Scholar 

  35. Mayer E, Naliboff B, Craig A. Neuroimaging of the brain-gut-axis: from basic understanding to treatment of functional GI disorders. Gastroenterology. 2006;131:1925–42.

    Article  PubMed  Google Scholar 

  36. Holstege G. Micturition and the soul. J Comp Neurol. 2005;493:15–20.

    Article  PubMed  Google Scholar 

  37. DeGroat W, Fraser M, Yoshiyama M, et al. Neural control of the urethra. Scand J Urol Nephrol Suppl. 2001;207:35.

    Article  Google Scholar 

  38. DasGupta R, Critchley H, Dolan R, Fowler C. Changes in brain activity following sacral neuromodulation for urinary retention. J Urol. 2005;174:2268–72. Aids in understanding of the effect of sacral neuromodulation in women.

    Article  PubMed  Google Scholar 

  39. DasGupta R, Fowler C. Urodynamic study of women in urinary retention treated with sacral neuromodulation. J Urol. 2004;171:1161–4.

    Article  PubMed  Google Scholar 

  40. Kavia R, DasGupta R, Critchley H, Fowler C, Griffiths D. A functional magnetic resonance imaging study of the effect of sacral neuromodulation on brain responses in women with Fowler’s syndrome. BJU Int. 2009;105:366–72.

    Article  PubMed  Google Scholar 

  41. Swinn M, Wiseman O, Lowe E, Fowler C. The cause and natural history of isolated urinary retention in young women. J Urol. 2002;167:151–6.

    Article  PubMed  Google Scholar 

  42. Duijkers I, Klipping C. Polycystic ovaries, as defined by the 2003 Rotterdam consensus criteria, are found to be very common in young healthy women. Gynecol Endocrinol. 2010;26:152–60.

    Article  PubMed  Google Scholar 

  43. Goodwin R, Swinn M, Fowler C. The neurophysiology of urinary retention in young women and its treatment by neuromodulation. World J Urol. 1998;16:305–7.

    Article  CAS  PubMed  Google Scholar 

  44. Burnett K, Tawadros C, Derbyshire L, Clarke N, Betts C. External urethral sphincter electromyographic activity (EMG) in asymptomatic women and the influence of the menstrual cycle…more questions than answers. BJU Int. 2013;111:52.

    Google Scholar 

  45. Ramm O, Mueller E, Brubaker L, Lowensteing L, Kenton K. Complex repetitive discharges—a feature of the urethral continence mechanism or a pathological finding? J Urol. 2012;187:2140–3.

    Article  PubMed  Google Scholar 

  46. Kujawa M, Reid F, Elis A, Clarke N, Betts C. Are “whaling” women normal. BJU Int. 2001;88:82.

    Google Scholar 

  47. Wiseman O, Swinn M, Brady C, Fowler C. Maximum urethral closure pressure and sphincter volume in women with urinary retention. J Urol. 2002;167:1348–52.

    Article  PubMed  Google Scholar 

  48. Andrich D, Rickards D, Landon D, Fowler C. Structural assessment of the urethral sphincter in women with urinary retention. J Urol. 2005;171:1161–4.

    Google Scholar 

  49. Fowler C, Betts C, Christmas T, et al. Botulinum toxin in the treatment of chronic urinary retention in women. BJU Int. 1992;70:387–9.

    Article  CAS  Google Scholar 

  50. DasGupta R, Wiseman O, Kitchen N, Fowler C. Long-term results of neuromodulation for women with urinary retention. BJU Int. 2004;94:335–7.

    Article  PubMed  Google Scholar 

  51. Swinn M, Kitchen N, Goodwin R, Fowler C. Sacral neuromodulation for women with Fowler’s syndrome. Eur Urol. 2000;38:439–43.

    Article  CAS  PubMed  Google Scholar 

  52. Groen L, Hoebeke P, Loret N, Van Praet C, Van Laeke E, Ann R, et al. Sacral neuromodulation with an implantable pulse generator in children with lower urinary tract symptoms: 15-Year Experience. J Urol. 2012;188:1313–8.

    Article  PubMed  Google Scholar 

  53. Peeters K, Sahai A, DeRidder D, Van Der Aa F. Long term follow up of sacral neuromodulation for lower urinary tract dysfunction. BJU Int. 2014;113:789–94.

    Article  PubMed  Google Scholar 

  54. “Important Safety Information” Medtronic. 2012. Retrieved May 27, 2014 from www.medtronic.com/patients/urinary-retention/important-safety-information.

  55. Khunda A, Karmarkar R, Abtahi B, Gonzales G, Elneil S. Pregnancy in women with Fowler’s syndrome treated with sacral neuomodulation. Int Urogynecol J. 2013;24:1201–4.

    Article  PubMed  Google Scholar 

  56. Leadbetter G, Leadbetter W. Diagnosis and treatment of congenital bladder-neck obstruction in children. NEJM. 1959;260:633–7.

    Article  PubMed  Google Scholar 

  57. Diokno A, Hollander J, Bennett C. Bladder neck obstruction in women: a real entity. J Urol. 1984;132:294–8.

    CAS  PubMed  Google Scholar 

  58. Turner-Warwick R, Whiteside C, Worth P, Milroy E, Bates C. A urodynamic view of the clinical problems associated with bladder neck dysfunction and its treatment by endoscopic incision and trans-trigonal posterior prostatectomy. BJU Int. 1973;45:44–59.

    Article  CAS  Google Scholar 

  59. Yalla S, Resnik N. Initiation of voiding in humans: the nature and temporal relationship of urethral sphincter responses. J Urol. 1997;157:590–5.

    Article  CAS  PubMed  Google Scholar 

  60. Crowe R, Noble J, Robson T, et al. An increase in neuropeptide Y but not nitric oxide synthase-immunoreactive nerves in the bladder from male patients with bladder neck dyssynergia. J Urol. 1995;154:1231–6.

    Article  CAS  PubMed  Google Scholar 

  61. Kuo H. Videourodynamic characteristics and lower urinary tract symptoms of female bladder outlet obstruction. Urology. 2005;6:1005–9.

    Article  Google Scholar 

  62. Nitti V. Primary bladder neck obstruction in men and women. Rev Urol. 2005;7:S12–7.

    PubMed Central  PubMed  Google Scholar 

  63. Brucker B, Fong E, Shah S, Kelly C, Rosenblum N, Nitti V. Urodynamic differences between dysfunctional voiding and primary bladder neck obstruction in women. Urology. 2012;80:55–60. Useful in the differentiation of dysfunctional voiding and primary bladder neck obstruction.

    Article  PubMed  Google Scholar 

  64. Hickling D, Aponte M, Nitti V. Evaluation and management of outlet obstruction in women without anatomical abnormalities on physical exam or cystoscopy. Curr Urol Rep. 2012;13:356–62.

    Article  PubMed  Google Scholar 

  65. Lee K, Han D, Lee Y, Choo M, Yoo T, Park H, et al. Efficacy and safety of tamsulosin for the treatment of non-neurogenic voiding dysfunction in females: a 8-week prospective study. J Korean Med Sci. 2010;25:117–22.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  66. Kessler T, Studer U, Burkhard F. The effect of terazosin on functional bladder outlet obstruction in women: a pilot study. J Urol. 2006;176:1487–92.

    Article  CAS  PubMed  Google Scholar 

  67. Costantini E, Lazzeri M, Bini V, Zucchi A, Fioretti F, Frumenzio E, et al. Open-label, longitudinal study of tamsulosin for functional bladder outlet obstruction in women. Urol Int. 2009;83:311–5.

    Article  PubMed  Google Scholar 

  68. Cisternino A, Zeccolini G, Calpista A, DeMarco V, Galetti T, Iafrate M, et al. Obstructive primary bladder neck disease: evaluation of the efficacy and safety of alpha-1 blockers. Urol Int. 2006;76:150–3.

    Article  CAS  PubMed  Google Scholar 

  69. Kumar A, Mandhani A, Gogoi S, Srivastava A. Management of functional bladder neck obstruction in women: use of alpha-blockers and pediatric resectoscope for bladder neck incision. J Urol. 1999;162:2061–5.

    Article  CAS  PubMed  Google Scholar 

  70. Blaivas J, Flisser A, Tash J. Treatment of primary bladder neck obstruction in women with transurethral resection of the bladder neck. J Urol. 2004;171:1172–5.

    Article  PubMed  Google Scholar 

  71. Zhang P, Wu Z, Xu L, Yang Y, Zhang N, Zhang X. Bladder neck incision for female bladder neck obstruction: long-term outcomes. Urology. 2014;83:762–7. Largest series of women with PBNO undergoing TUIBN.

    Article  PubMed  Google Scholar 

  72. Markic D, Maricic A, Oguic R, Spanjol J, Rahelic D, Rubinic N, et al. Transurethral baldder neck incision in women with primary bladder neck obstruction. Wien Klin Wochenschr. 2014;126:217–22.

    Article  PubMed  Google Scholar 

  73. Peng C, Kuo H. Transurethral incision of bladder neck in treatment of bladder neck obstruction in women. Urology. 2005;65:275–8.

    Article  PubMed  Google Scholar 

  74. Jin X, Qu H, Liu H, Li B, Wang J, Zhang Y. Modified transurethral incision for primary bladder neck obstruction in women: a method to improve voiding function without urinary incontinence. Urology. 2012;79:310–3.

    Article  PubMed  Google Scholar 

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Conflict of Interest

Dr. Ashley B. King declares no conflicts of interest.

Dr. Howard B. Goldman is a speaker and consultant for Medtronic, Allergan, and Uroplasty. Dr. Goldman is a section editor for Current Urology Reports.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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  1. Center for Female Pelvic Medicine and Reconstructive Surgery, Glickman Urological and Kidney Institute, Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave. Q10, Cleveland, OH, 44195, USA

    Ashley B. King & Howard B. Goldman

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Correspondence to Ashley B. King.

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This article is part of the Topical Collection on Lower Urinary Tract Symptoms & Voiding Dysfunction

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King, A.B., Goldman, H.B. Bladder Outlet Obstruction in Women: Functional Causes. Curr Urol Rep 15, 436 (2014). https://doi.org/10.1007/s11934-014-0436-z

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