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Bladder outlet obstruction

What's new

Added 2024 EAU and 2023 AUA guidelines for the diagnosis and management of bladder outlet obstruction.

Background

Overview

Definition
BOO is a condition characterized by an impediment to the flow of urine from the bladder to the urethra, leading to urinary retention and increased detrusor pressure.
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Pathophysiology
The pathophysiology of BOO is multifactorial and can be caused by a variety of conditions, involving anatomical, neurologic, and functional etiologies. Anatomical causes include BPH, urethral stricture, urethral diverticulum, urethral caruncle, urethral leiomyoma, uterine fibroids, pelvic organ prolapse, rectal cancer, bladder cancer, and bladder stones; neurologic causes include neurogenic bladder; and functional causes include dysfunctional voiding, primary bladder neck obstruction, and Fowler's syndrome.
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Epidemiology
The prevalence rates of LUTS due to BOO is estimated at 18.7-18.9% and 24.3-24.7% in women and men, respectively.
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Disease course
Clinically, BOO can present with a range of symptoms from mild urinary frequency and urgency to severe urinary retention. Other symptoms can include a weak or interrupted urine stream, straining to urinate, and a sensation of incomplete bladder emptying.
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Prognosis and risk of recurrence
The prognosis of BOO largely depends on the underlying cause and the timeliness of treatment. If left untreated, BOO can lead to complications such as UTIs, bladder damage, and in severe cases, renal failure.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of bladder outlet obstruction are prepared by our editorial team based on guidelines from the Canadian Urological Association (CUA 2024,2022), the European Association of Urology (EAU 2024), the European Association of Urology (EAU/EAUN 2024), the American Urological Association (AUA 2023), and the American Urological Association (AUA/SUFU 2014)....
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Screening and diagnosis

Indications for testing: as per AUA 2023 guidelines, Consider evaluating patients with bladder diverticulum for the presence of BOO.
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Classification and risk stratification

Classification: as per EAU/EAUN 2024 guidelines, Use standardized classification of BOO (anatomical or functional).
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Diagnostic investigations

History and physical examination: as per EAU/EAUN 2024 guidelines, Elicit a complete medical history and perform a thorough physical examination in patients with suspected BOO.
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More topics in this section

  • Urodynamic studies

  • Post-void residual volume

  • Urinary tract imaging

  • Urinalysis

  • Urinary biomarkers

Diagnostic procedures

Cystoscopy: as per EAU/EAUN 2024 guidelines, Perform cysto-urethroscopy in patients with suspected anatomical BOO.
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Medical management

Alpha-blockers: as per EAU/EAUN 2024 guidelines, Offer uroselective α-blockers in female patients with functional BOO following a discussion of the potential benefits and adverse events.
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  • Baclofen

  • Sildenafil

  • Thyrotropin-releasing hormone

Nonpharmacologic interventions

Pelvic floor muscle training: as per EAU/EAUN 2024 guidelines, Offer pelvic floor muscle training aimed at pelvic floor muscle relaxation in female patients with functional BOO.
B

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  • Vaginal pessary

  • Urinary containment devices

  • Intraurethral devices

Therapeutic procedures

Intra-sphincteric botulinum toxin injection: as per EAU/EAUN 2024 guidelines, Offer intra-sphincteric injection of botulinum toxin in female patients with functional BOO.
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More topics in this section

  • Urethral dilatation

  • Sacral neuromodulation

Surgical interventions

Internal urethrotomy: as per EAU/EAUN 2024 guidelines, Offer internal urethrotomy with postoperative urethral self-dilatation in female patients with BOO due to urethral stricture disease, while informing about its limited long-term improvement and the risk of postoperative urinary incontinence.
B
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More topics in this section

  • Bladder neck incision

  • Urethroplasty

  • Urethrolysis

  • Sling revision

Specific circumstances

Patients with bladder stones: as per EAU 2024 guidelines, Perform procedures for the bladder stone and underlying BOO simultaneously, where possible, in adult patients with bladder stones secondary to BOO.
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