When the going gets tough
View(s):Smriti Daniel speaks with Dr. Anura Wijewardane, Consultant Urologist about bladder outflow obstruction
The first catheters to help relieve bladder outflow obstructions were reportedly used as far back as 5th century BC. In Hippocrates time they were made of metal. The ancient physician’s modern counterparts are considerably better equipped. When it comes to the passage of your urine, state of the art labs are able to test every possibility: they can study the chemical markers for clues that reveal the health of your prostate and have the equipment to gauge the pressure your bladder is able to exert and the know how to compare it to what others in your age group can muster.
This week, MediScene speaks with Dr. Anura Wijewardane, a consultant urologist about bladder outflow obstruction. Among men it is one of the most common urological problems, he says, adding that women can develop the condition as well. An increasing number of cases of urinary stones, prostate disease, urinary tract cancers and infections have been linked to a rise in cases of ‘lower urinary tract symptoms’ involving difficulty and/or discomfort while urinating. A block can occur at any point in the urinary tract; if neglected it can pose a serious health risk. The trick lies in diagnosing the underlying problem correctly.
What causes a bladder outflow obstruction?
Comparing the bladder to a kind of muscular balloon, Dr. Wijewardane explains that it is located in the lower part of the abdomen and that the little sac can stretch to contain average 15 ounces of urine and allow a person to store it for even up to four to five hours. “The excess water and waste is filtered from the kidneys down to the bladder through the tubes known as the ureters,” he says. Nerves from the bladder tell the brain when it’s full. When it is time to pass urine, the bladder muscles contract, squeezing out their contents. The brain simultaneously signals the sphincter controlling the entry to the urethra to loosen and open, allowing the urine to pass into the tube and out of your body.
“An obstruction can appear in any section of the urinary tract, i.e from the exit or neck of the bladder to the terminal end of the urethra,” explains Dr. Wijewardane. Some children develop a condition known as Lower Urinary Tract Obstruction or LUTO in the womb. “Patients are born with it,” explains Dr. Wijewardane explaining that in some cases of LUTO the culprit is the posterior urethral valve that blocks the lumen of the urethra. It often requires surgical intervention.
While this condition is known to afflict women, the most common cause of bladder outflow obstruction is the enlargement of the prostate gland in men, says Dr. Wijewardane. The prostate gland is the organ that produces the fluid that help to nourish sperm. Most men who live past the age of 60 will display an enlarged prostate gland. (The onset of enlargement is around 45 years of age.) The first part of the urethra passes through its centre, and so when the prostate enlarges, it can block or obstruct the flow through the tube. The majority of such enlargements are benign, while a small percentage of cases will prove malignant.
Bladder outflow obstruction is also caused by strictures – little scars that form along the urethra, usually due to trauma, injury or infection. “When a scar forms in the tube in a circular fashion the diameter can get restricted,” says Dr. Wijewardane. Infections in urethra in young men that result in strictures in later life are common. Other causes can include bladder stones, tumours in the bladder and pelvic region as well as urethral diverticula – a condition in which the urethra protrudes into the anterior vaginal wall. In elderly women, a lack of oestrogen can cause urethral stenosis. Another common condition that affects women is a cystocele, when the bladder descends into the vagina.
What are the symptoms?
Symptoms can be divided into two categories, explains Dr. Wijewardane: storage and voiding. While the underlying causes can vary, the symptoms typically include , a continuous feeling of a full bladder, a frequent urge to urinate, having to use the toilet multiple times in a night, an inability to urinate, pain during urination, problems starting urination, slow urine flow, or intermittent flow. “We call these lower urinary tract symptoms,” says Dr. Wijewardane saying that the bladder activity can also be adversely affected so that the bladder muscle contracts more often than normal. “Patients develop an unstable bladder due to the blockage,” he adds.
“Retention of urine causing distended bladder is a complication of bladder outflow obstruction,” cautions Dr. Wijewardane. Another complication is the development of hydronephrosis, literally meaning water inside the kidney, which is associated with an enlargement/dilation of the kidney. The two ureters can also get dilated causing a condition called hydroureters.
Diagnosing the problem:
Your doctor will want to examine you thoroughly as well as take down a comprehensive medical history. In cases of acute retention, a patient is likely to complain of severe pain in the lower part of abdomen. Some patients however may spend a long time with a distended bladder and never have much pain to speak of. This state is called chronic retention of urine.
To asses the prostate enlargement as a cause in men, a doctor will have to do a digital rectal examination to assess the size of the prostate and also to check its consistency- whether it is soft, firm or hard. The harder the gland the more likely it is malignant, and though there are exceptions to the rule, a hard prostate gland is a matter of some concern. The genitals will also need to be examined to rule out any obvious causes of obstruction says Dr. Wijewardane.
Ultrasound scans can also be used to help to asses upper and lower urinary tracts. It can also pick up issues like kidney stones, along with the shape and the size of the kidney. “Ultrasound is a very important test in this context,” he says. Urine and blood tests are mandatory.
Most of the time the basic tests will allow for a clear diagnosis but in some cases, more sophisticated tests are called for. A fully equipped urodynamics lab like the one Dr. Wijewardane has access to at Asiri Surgical Hospital, will allow for a thorough investigation of the lower urinary tract functions, including physical measurements such as bladder pressure and flow rate as well as clinical assessment that can provide the data on bladder dysfunctions like incontinence and equivocal outflow obstruction specially to distinguish cases of bladder outflow obstruction from atonic bladders where the bladder is simply not strong enough. Measurement of speed of urine flow is known as Uroflowmetry and is a helpful test in diagnosis
The PSA (Prostate Specific Antigen) test is used to gauge the activity of the prostate gland – the higher the value of the test, the greater the warning that a serious assessment of this patient is required. A biopsy will help determine whether it is malignant or benign. Men with first degree relatives who’ve been diagnosed with prostate cancer should talk to their doctor about how often they need to be tested. “Although this test is not diagnostic of malignancy, this helps to prioritize the patients for further evaluation,” says Dr. Wijewardane.
Treatment
Treatment can vary dramatically based on the underlying cause. An enlarged prostate which is not cancerous is known as benign prostatic hyperplasia or (BPH). A doctor will decide on the treatment depending upon the severity of the symptoms and to what extent they affect your health and wellbeing. Medication is prescribed in patients with moderate symptoms. Surgery is considered an option in patients with severe symptoms, who fail to respond to medication or in patients with complications with bladder outflow obstruction.
In some cases of bladder outflow obstruction leading to acute retention of urine, your doctor may suggest you the use of a catheter, inserted through the urethra into the bladder or through the belly area into the bladder, to help relieve the blockage. This is an immediate step to relieve the blockage until the definitive intervention to relieve the obstruction. Surgery typically involves a minimally invasive procedure carried out via the urethra called Transurethral Resection of Prostate [TURP]. “The technique and technology have immensely improved in this procedure to eliminate its past complications,” says Dr. Wijewardane. “Even though from time to time TURP has been challenged by other newer techniques like Holmium Laser Enucleation of Prostate, TURP still maintain its status as the gold standard in surgical treatment of benign prostate disease.”
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