Voiding Disorders

1. VOIDING DISORDERS
 Presented By:
 Sukhpreet Kaur
PPT-3

2. Function of Lower Urinary
Tract
 STORAGE of adequate volumes of urine at low
pressure & with no leakage
 EMPTYING that is
 Voluntary
 Efficient
 Complete
 Low pressure
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3. Anatomy of the Lower Urinary
Tract
 Bladder (detrusor)
 Stores urine at low pressure
 Compresses urine for voiding
 Urethra
 Conveys urine from bladder to outside world
 Sphincter(s) internal & external
 Controls urine flow & maintain continence
between voidings
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4. ADULT VOINDING DYSFUNCTION
1.URINARY INCONTINENCE:-
 Urinary incontinence means
involuntary urination or leakage
of urine.
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5. EPIDEMIOLOGY
 More than 17 million adults in the
united states are estimated to have
urinary incontinence.
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6. RISK FACTORS
 Pelvic muscle weakness
 Age- related changes
 Urinary disorders
 High-impact exercise
 stress
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7. TYPES
 STRESS INCONTINENCE
 URGE INCONTINENCE
 REFLEX INCONTINENCE
 OVERFLOW INCONTINENCE
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8. MANAGEMENT
 Behavioral therapy
 Pharmacologic therapy
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9. 2.URINARY RETENTION
 Urinary retention is inability to empty the
bladder completely during attempts to
void.
CAUSES:-
Prostatic enlargement
Pregnancy
Infection
Neurologic disorders
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10. 3.NEUROGENIC BLADDER
 Neurologic bladder is a dysfunction that
results from a lesion of the nervous
system.
 CAUSES
 Spinal injury
 Multiple sclerosis
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Benign Prostatic Hyperplasia
 Generalised disease of the
prostate due to hormonal
derangement which leads
to enlargement of the
gland .

12. INCIDENCES
 Occurs in 50% of men over 50 and in 80% of
men over 80 have BPH.
 Many men with BPH may have mild
symptoms and may never need treatment.
 In India total no patients 1,696,347.
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13. BPH Etiologies
 Cause not completely understood
 Change in hormonal with alterations in the
testosterone/estrogen balance
 Induction of prostatic growth factors
 Increased stem cells
 Accumulation of dihydroxytestosterone.

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Benign Prostatic Hyperplasia

15. BPH Pathophysiology
Normal BPH
Hypertrophied
detrusor muscle
Obstructed
urinary flow
PROSTATE
BLADDER
URETHRA
Kirby RS et al. Benign prostatic hyperplasia. Health Press, 1995.

16. BPH
Pathophysiology
 Slow and insidious changes over time
 Complex interactions between prostatic urethral
resistance, intravesical pressure, detrussor
functionality, neurologic integrity, and general
physical health.
 Initial hypertrophydetrussor decompensation
poor tonediverticula formationincreasing urine
volumehydronephrosisupper tract dysfunction

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Clinical manifestations
 Voiding symptoms
 decrease in the urinary stream
 Dribbling at the end of urination
 Hesitancy
 Pain or burning during urination
 Feeling of incomplete bladder emptying

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Clinical manifestations
 Irritative symptoms
urinary frequency
dysuria
bladder pain
nocturia
incontinence
symptoms associated with infection

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Diagnostic Tests
 History & Examination
 Digital rectal exam (DRE)
 Urinalysis
 Urine culture
 BUN
 Prostate specific
antigen (PSA)
 Transrectal
ultrasound – biopsy
 Uroflometry

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DRE

22. MANAGEMENT OF BPH
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23. MANAGEMENT OF BPH
 Catheterization (stylet)
 Watchful waiting and behavioral modification
 Medical Management
 Alpha blockers
 5-alpha reductase inhibitors
 Combination therapy
 Surgical Management
 Urethral stents

24. Watchful Waiting and Behavioral
Modification
 “is the preferred management technique in
patients with mild symptoms.
 AUA score < 7,

25. Watchful Waiting and Behavioral
Modification
 Decrease caffeine, alcohol )diuretic effect(
 Avoid taking large amounts of fluid over a short
period of time
 Void whenever the urge is present, every 2-3 hours
 Maintain normal fluid intake, do not restrict fluid
 Avoid bladder irritants to include dairy products,
artificial sweeteners, carbonated beverages
 Limit nighttime fluid consumption
 BPH symptoms can be variable, intermittent

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Medical Management
Alpha adrenergic receptor blockers
 promote smooth muscle relaxation in the prostate
 Relaxation of the muscles facilitates urinary flow
 Doxazosin (Cardura), Terazosin (Hytrin),
Tamsulosin (Flomax), Alfuzosin (Uroxatral)

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Medical Management
5 alpha reductase inhibitor )finasteride :
Proscar(
 Reduce size of prostate gland by up to 30 %
 Blocks the enzyme of 5 alpha reductase
which is necessary to stop the conversion of
testosterone to dihydroxytestostersone

28. Combination Therapy
 Concomitant use of alpha blockers and
5-alpha reductase inhibitors
 Should be reserved for patients who
are at significant risk of progression
and adverse outcome
 Poor surgical candidate
 Patient wants to avoid surgery
 Significant cost associated with dual
medications

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Medical Management
 Herbal therapy –
saw palmetto fruit –
use to improve
urinary symptoms
and urinary flow
 Problem with herbal
therapy – long term
effectiveness

30. surgical treatment

31. Surgical Management
 Minimally Invasive techniques
 1. Transurethral Microwave thermotherapy
 2.Transurethral needle ablation.

32. Surgical Management
 Open simple prostatectomy
 TURP (Transurethral Prostatectomy)
 Transurethral incision of the prostate
 Laser Prostatectomy

33. TURP
“Gold Standard” of care for BPH

34. NURSING MANAGEMENT
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Preoperative care
 Antibiotics
 Allow pt to discuss concerns about
surgery on sexual functioning
 Prostatic surgery may result in
retrograde ejaculation

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Postoperative Goals
 No complications
 Restoration of urinary control
 Complete bladder emptying

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Postoperative Care
 Monitoring
 Continuous irrigation & maintain catheter
patency
 Blood clots and hematuria are expected for
the first 24-36 hours
 After catheter is removed – check for urinary
retention and urinary stream

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Discharge planning
 Catheter care
 Managing urinary incontinence
 Oral fluid intake – 2,000-3,000 cc per day
 Observe for s/s of urinary tract infection
 Prevent constipation
 Avoid lifting
 No driving or intercourse after surgery

39. BPH TREATMENT
New Modalities
 Minimally invasive: (Prostatic
Stents,TUNA,TUMT, HIFU,Water-
induced Thermotherapy)
 Laser prostatectomy
(VLAP,ILC,CLAP,TULIP,HoLRP)
 Electrovaporization (TUVP,TVRP)

40. summary
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