BLADDER OUTFLOW

OBSTRUCTION
Codillia Cheong
Liew Li Gin
Ooi Jia Ling

ANATOMY OF URINARY BLADDER &

URETHRA

URINARY
BLADDER
Gross
Anatomy

2
trigone

Rugae: Mucosal fold of

inner surface of bladder.

Trigone: Triangular area of

the mucosal surface where
mucosa always remain
smooth

Uvula Vesicae: Small

elevation behind the
internal urethral orifice. It
is produce by the median
lobe of prostate.

rugae

uvula
vesicae

median
lobe

PHYSIOLOGY OF MICTURITION

Micturition is the process of expulsion of urine from the

bladder.

It is a spinal reflex which results in the contraction of

the detrusor muscle & relaxation of the external
sphincter.

The 1st urge is felt at 150 ml (may be voluntarily

controlled by external sphincter)

Facilitated/inhibited by higher centers

- exerts final control of micturition
Voluntary facilitation or inhibition

INNERVATIONS

Parasympathetic via
pelvic splanchnic nerves
to S.2,3,4 segments.

Sympathetic via
hypogastric plexuses to
L.1,2 segments.

Somatic via the

pudendal nerve and
S.2,3,4

ACTIONS
Parasympathetic nerves:

Stimulate contraction of detrusor muscle.

Inhibit contraction (i.e. relaxation) of sphincter vesicae.

Sympathetic nerves:

Inhibit contraction of detrusor muscle

Stimulate contraction of sphincter vesicae

Pudendal nerves:

Relaxes sphincter urethrae (during micturition).

Laplace Law: In the bladder, tension increases as the

urine is filled. The radius also increases due to
relaxation of the detrusor muscle. Because of this, the
pressure rise is almost nil.

During filling:

bladder wall stretches will initiate a reflex contraction

which has lower threshold not trigger micturition
reflex.

When bladder is filled about 300 400 mL of

urinesharp rise in the intravesical pressure the
micturition reflex is triggered.At this point also
voluntary control is possible

Beyond 600 700 mL of urine voluntary control starts

failing involuntary voiding

BLADDER OUTFLOW OBSTRUCTION

Definition: Blockage at the base of the bladder that

reduce or prevent flow of urine into the urethra.

It is associated with increased voiding pressures with

low urinary flow rates.

Causes can be divided based on mechanical and

functional causes or based on gender and age.

Complication:
1.
2.
3.
4.
5.

Renal failure
Recurrent urinary tract infection
Urinary incontinence
Urinary retention
Bladder and renal calculi

AETIOLOGY BOO
Mechanical
Extramural
Intraluminal
Ovarian cyst
Blood clot
Pregnancy
Stone
Fibroids
Prolapsing
Pelvic mass
bladder
Faecel
tumour
impaction
Urethral
valves
(congenital)
Intramural
BPH
Prostatitis
Prostate cancer
Urethal stricture

Neurological
Post operative
Spinal cord injury
(disc prolapse)
Drugs
(anticholinergic,
narcotics,
antihistamines,
antipsychotics)
Diabetes
Idiopathic

COMMON CAUSES OF BOO

In Children
Posterior Urethral Valve
Phimosis

Male

Female

<40 years
Urethritis
Trauma

Pre-menopausal

UTI/PID
Pregnancy
Fibroid
Ovarian cyst

>40 years
BPH
Prostatitits
Prostatic cancer

Post-menopausal

UTI
Urethral
stenosis
Gynaecological
malignancy

CLINICAL FEATURES
OBSTRUCTIVE
(VOIDING)

IRRITATIVE
(FILLING)

Due to bladder
outflow impedance

Due to detrusor
instability
(involuntary
contraction of the
distended bladder)

Difficulty in
starting urination
(hesitancy)
Difficulty in passing
urine
Poor and
intermittent stream
Dribbling at the
end of micturition
(terminal dribbling)
Haematuria
(usually at the end
of micturition)
*If bladder fails to

Frequency
Urgency
Nocturia
Overflow
incontinence

SYMPTOMS OF
SEQUELAE (Infection
or renal failure)
Neurological :
weakness, fatigue,
drowsiness, confusion,
seizure, coma
Cardiopulmonary :
breathlessness
Gastrointestinal :
nausea, vomiting,
anorexia
Haematological :
anaemia

TYPES OF RETENTION
ACUTE RETENTION

CHRONIC RETENTION
Painful condition
Painless condition
Pressure cause sensation Pressure/touch- no
to urinate (intense urge)
sensation to urinate
Well defined palpable &
Bladder percussible but
tender bladder, dull on
not well palpable/tender
percussion

Exception if infection supervenes on chronic retention

because this makes the bladder painful (acute-onchronic retention)

NO URINE OR
INABILITY TO PASS URINE??
ANURIA
RETENTION OF URINE
Urge to void but unable No urge to void
to push urine out of
Due to
bladder
Urine not being produce
(pre-renal & renal)
Due to
Infravesical obstruction
Inability to generate
effective detrusor
contractions

Catheterization- yields
urine relieving
symptoms

Urine not reaching

urinary bladder (postrenal & obstructive)

Catheterization- no
urine is drained

CAUSES OF RETENTION OF URINE

CHRONIC RETENTION

ACUTE RETENTION
MALE

Bladder outlet obstruction

(Commonest)
Urethral stricture
Acute urethritis or prostatitis
Phimosis

BOTH

Benign prostatic
hypertrophy (BPH)
Carcinoma of prostate
Urethral stricture
Hypertrophy of bladder
FEMAL Retroverted gravid uterus
E
Bladder neck obstruction (rare)
neck (younger age)
Blood clot
Urethral calculus
Rupture of urethra
Neurogenic (injury or disease
of spinal cord)
Faecal impaction
Spinal anaethesia
Drug (antihistamine,
antihypertensive,
anticholinergic, tricyclic
antidepressants)

Dementia
CVA (Spinal)
Parkinson disease
Multiple sclerosis
Diabetes Mellitus
Urethral carcinoma
Bladder carcinoma

PROSTATE
CANCER

Screening for prostate

cancer
The cancer detection rate using
measurement of PSA is between 2% and
4% and approximately 30% of men with an
elevated PSA will have prostate cancer
confirmed biopsy.
Unfortunately, 20% of men with clinically
significant prostate cancer will have PSA
values within the normal range.
There is a controversy over the usefulness
of PSA alone as a screening procedure.
Age >70 years

Clinical Features
Advanced disease
BOO
Perineum pain and haematuria
Bone pain, malaise, arthritis, anemia,
pancytopenia
Pathological fracture
Renal failure
Locally advanced disease or even asymptomatic
metastases, which may be found incidentally on
investigation of other symptoms
Secondary mets: bone

Per Rectal Examination

Nodules within the prostate
Irregular induration, characteristically
stony hard in part or in the whole of
the gland
Extension beyond the capsule up into
the bladder base, seminal vesicle and
rectal wall is diagnostic, as is local
extension through the capsule

Investigation
Blood test : FBC, FDPs, LFT
Prostate - specific antigen (PSA)
PSA > 10 nmol/ml suggestive of cancer
PSA > 35 nmol/ml almost diagnostic of
advanced prostate cancer.

TRUS with prostatic biopsy

Imaging : CXR, MRI
Bone scan

TNM staging
Tumour
T1 clinically inapparent tumour neither
palpable nor visible by imaging
T2 tumour confined within prostate
T3 tumour extends through the prostate
capsule
T4 tumour is fixed or invades adjacent
structure other than seminal vesicle:
bladder neck, external sphincter, rectum,
levator muscle and/ or pelvic wall

 Nodal
N1 nodal metastasis

Metastasis
M1 distant metastasis

Treatment
Surgery
Radical prostatectomy
removal of whole prostate until distal sphincter and
seminal vesicle
T1 ad T2

Radiotherapy
External beam radiotherapy (EBRT)
T1, T2 and locally advanced T3.

Brachytherapy
Radioactive seed is permanently seeded in prostate
Iodine -125 and palladium - 103
T1 disease

 Androgen ablation
Orchidectomy
Locally advanced disease (T3 and T4)
Eliminate the major source of testosterone
production

Medical
LHRH agonist goserelin
Anti androgenic flutamide, bicalutamide,
cyproterone