Материал: Oxford American Handbook of Urology ( PDFDrive )
URETHRAL STRICTURE DISEASE 107
Treatment options
Urethral dilatation
This is designed to stretch the stricture without causing more scarring; bleeding post-dilatation indicates tearing of the stricture (i.e., further injury has been caused) and restricturing is likely.
Internal (optical) urethrotomy
This procedure involves stricture incision, with an endoscopic knife or laser. The stricture is divided, followed by epithelialization of the incision. If deep spongiofibrosis is present, the stricture will recur.
It is best suited for short (<1.5 cm) bulbar urethral strictures with minimal spongiofibrosis.1 Leave a catheter for 3–5 days (longer catheterization does not reduce long-term restricturing).
Consider ISC for 3–6 months, starting several times daily, reducing to once or twice a week toward the end of this period.
Excision and reanastomosis or tissue transfer
Treatment involves excision of the area of spongiofibrosis with primary reanastomosis or closure of defect with buccal mucosa or pedicled skin flap; this has best chance of cure.
A stepwise progression up this reconstructive ladder (the process of starting with a simple procedure and moving onto the next level of complexity when this fails) is not appropriate for every patient. For the patient who wants the best chance of long-term cure, offer excision and reanastomosis or tissue transfer up front.
For the patient who is happy with lifelong management of his stricture (with repeat dilatation or optical urethrotomy), offer dilatation or optical urethrotomy.
Balanitis xerotica obliterans (BXO)
BXO is genital lichen sclerosis and atrophicus in the male. Hyperkeratosis is seen histologically. BXO appears as a white plaque on the foreskin, glans of the penis, or within the urethral meatus. It is the most common cause of stenosis of the meatus.
The foreskin becomes thickened and adheres to the glans, leading to phimosis (a thickened, nonretractile foreskin). Patients with long-standing BXO and meatal stenosis often have more proximal urethral strictures.
1 Pansadoro V, Emiliozzi P (1996). Internal urethrotomy in the management of anterior urethral strictures: long term follow-up. J Urol 156:73–75.
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Chapter 4 |
109 |
Incontinence |
|
Classification 110
Causes and pathophysiology 112 Evaluation 114
Treatment of sphincter weakness incontinence: injection therapy 116
Treatment of sphincter weakness incontinence: retropubic suspension 117
Treatment of sphincter weakness incontinence: pubovaginal slings 118
Treatment of sphincter weakness incontinence: the artificial urinary sphincter 120
Overactive bladder: conventional treatment 122 Overactive bladder: options for failed conventional
therapy 124
“Mixed” incontinence 126 Post-prostatectomy incontinence 128 Vesicovaginal fistula (VVF) 130 Incontinence in the elderly patient 132
110 CHAPTER 4 Incontinence
Classification
Definition
The International Continence Society (ICS) defines incontinence as “involuntary loss of urine that is a social or hygienic problem and is objectively demonstrable.” Urinary incontinence (UI) is a failure to store urine usually due to either abnormal bladder smooth muscle or a deficient urethral sphincter. Urine loss may also be extraurethral, secondary to anatomical abnormalities such as ectopic ureter or vesicovaginal fistula.
Prevalence
UI has been reported to affect 12–43% of adult women and 3–11% of adult men. Severe incontinence has a low prevalence in young women, but rapidly increases at ages 70 through 80. Incontinence in men also increases with age, but severe incontinence in 70to 80-year-old men is about half that in women.
Classification
Stress urinary incontinence (SUI) is involuntary urinary leakage during effort, exertion, sneezing, or coughing, due to hypermobility of the bladder base, pelvic floor, and/or intrinsic urethral sphincter deficiencies. In females SUI is usually associated with multiparity. In males, SUI is most commonly the result of prostatectomy.
•Type 0—report of urinary incontinence, but without clinical signs
•Type I—leakage that occurs during stress with <2 cm descent of the bladder base below the upper border of the symphysis pubis
•Type II—leakage on stress accompanied by marked bladder base
descent (>2 cm) that occurs only during stress (IIa) or is permanently present (IIb)
•Type III—bladder neck and proximal urethra are open at rest (with or without descent). Also known as intrinsic sphincter deficiency (ISD)
Urge urinary incontinence (UUI) is involuntary urine leakage accompanied or immediately preceded by a sudden, strong desire to void (urgency).
Mixed urinary incontinence is urine leakage that has characteristics of both SUI and UUI.
Overflow incontinence is leakage of urine when the bladder is abnormally distended with large post-void residual volumes. Typically, men present with chronic urinary retention and dribbling incontinence. This can lead to hydronephrosis and renal failure in 30% of patients.
Nocturnal enuresis describes any involuntary loss of urine during sleep. The prevalence in adults is 0.5%. Approximately 750,000 children over age 7 years will regularly wet the bed. Childhood enuresis can be further classified into primary (never been dry for longer than a 6-month period) or secondary (re-emergence of bed wetting after a period of being dry for at least 6–12 months).
CLASSIFICATION 111
Post-micturition dribble is the complaint of a dribbling loss of urine that occurs after voiding. It predominantly affects males and is due to pooling of urine in the bulbous urethra after voiding. It affects approximately 20% of healthy adults1 and 60–70% of those with existent LUTS.2
1 Furuya S, Ogura H, Tanaka M, et al. (1997). Incidence of postmicturition dribble in adult males in their twenties through fifties. Hinyokika Kiyo 43(6):407–410.
2 Paterson J, Pinnock CB, Marshall VR (1997). Pelvic floor exercises as a treatment for postmicturition dribble. Br J Urol 79(6):892–897.