Good evening, and welcome to the AUGS Urogynecology Webinar Series. I'm Mary Duarte, a member of the AUGS Education Committee and the moderator for today's webinar. Today's webinar is titled, Chronic Urinary Retention, Causes, Diagnosis, and Management. Our speaker today is Dr. John Stoffel. Dr. Stoffel is a Lapides Family Research Professor and Chief of the Division of Neuro-Urology and Pelvic Reconstruction within the University of Michigan Department of Urology. He attended Stanford University as an undergraduate, Washington University in St. Louis for medical school, and completed his urology residency at Massachusetts General Hospital and the Leahy Clinic. This was followed by a female neuro-reconstructive urology fellowship at the University of Michigan. Dr. Stoffel is an active clinician and surgeon, and his clinical and research interests include bladder physiology, neurogenic bladder, and complex abdominal reconstructive surgery. He has received several federal and industry-sponsored grants to study these topics, and has published numerous papers, book chapters, and a textbook on these topics. He is board certified in female pelvic medicine and reconstructive surgery, and a member of the Society of Female Pelvic Medicine and Neurogenital Reconstruction, and the Society of Genitourinary Reconstructive Surgeons. He is a founding member of the Neurogenic Bladder Research Group, a research collaborative of 14 institutions across the United States and Canada. He has held national and regional leadership positions in neurologic associations, chaired federal grants study sessions, and is currently serving as the president of the North Central Section of the American Neurologic Association. Before I begin, I'd like to review some housekeeping items. Our presentation will last about an hour, with the first 45 minutes consisting of our lecture and the last 15 minutes of the webinar, which will be dedicated to Q&A. AUGS designates this live activity for a maximum of one CME credit. In order to claim this credit, you must log into the AUGS eLearning portal and complete the evaluation following completion of the webinar. The webinar is being recorded and live streamed. A recording of the webinar will be made available in the AUGS eLearning portal. Please use the Q&A feature of the Zoom webinar to ask the speaker any questions, and we will answer them at the end of the presentation. Use the chat feature if you have any technical issues, and the AUGS staff will be monitoring the chat and can assist. All right, Dr. Stoffel, you may begin. Well, thank you so much for the kind introduction. It's an absolute pleasure to talk to people, and thanks to AUGS for putting on these lecture series. I think they're a tremendous resource, and I'm honored and pleased to be part of it. So thank you very much. You'll have to excuse me. I may have a bit of a cough today recovering from a cold, as I'm sure many people out there also are. So today we're going to talk about chronic urinary retention, and talk about the causes, the diagnosis, and the management of it. It's a complicated topic, and so we're going to try to walk through the different aspects of it, and save some time at the end for some discussion. So these are my disclosures. And I'd like to break this down into essentially three sections, and definitions and diagnosis. It's good to kind of know how we're thinking about it, and how do we get to that definition. I want to go on a little bit into neurobiology, or discuss why we think it works, and what are the different aspects of this somewhat complicated topic. Then I also want to talk then about treatment, and maybe most important, what we want to do, and even more important, when not to do anything about this. So let's get started. So this is our index patient. This is a 58-year-old woman, and she has no significant medical history. She's coming in for urinary frequency. This is a pretty typical patient that we see in many of our different practices. You take a history. She has incomplete emptying. She does note a slow stream, and she's warning about every two to three hours, mild urgency. And it bothers her, the symptoms of incomplete emptying, though. You do a physical exam. There's no stress incontinence. There's no prolapse to speak. She has a relatively normal pelvic floor tone. You get some preliminary data, and show that there was a normal urinalysis. And then you get a post-void residual, and it shows that there's 300 cc's. And so now, what do you do? This is a relatively common patient that we see. And we think about, you know, what are the different ways we describe this? Is this chronic urinary retention? Is it incomplete emptying? Is this normal? And so I want to go through all the different aspects of this, and kind of help formulate the thought of chronic urinary retention. And so let's start with first, like, how do we do the post-void residuals? And so there's no standard process for it, but common sense is it should be sometime soon after voiding. Usually recommend about 20 minutes after voiding. Good to know their fluid intake. If somebody is drinking a Mountain Dew or a large coffee, you know, probably want to get it a little bit sooner after they void, but want to get it that's going to reflect what they finished, what's left in the bladder after they finished, and not what continues to keep filling. The most common way to measure post-void residuals with an ultrasound, and most common of that is the transabdominal technique. There are some reports and some ways to be able to do a transvaginal, but most broader scanners people are familiar with are the transabdominal ones. And so most of this is a calculation. And so the volume is really calculated by this formula that's listed there of length, width, height times 0.52. And this is kind of a typical picture of what you see is the vaginal stripe at the bottom there. The bladder is outlined. What you define is the bladder by its fluid-filled shape. And then this calculation is performed. So if the post-void residual, though, doesn't have to be done with an ultrasound, it can also be done with intermittent catheterization. And this is usually performed again, same timeframe, immediately after voiding. And usually recommend using a 12 or 14 French straight catheter. This does not need to be done in a sterile technique. It can be done with just a regular clean technique like what people do in intermittent catheterization. So there is a small risk of urethral trauma with this. It's very low. There's also a risk of urinary tract infection. And this is also pretty low if prepared correctly, a little bit more invasive than taking the ultrasound measurement, but still a very safe procedure. If you compare it, there's a nice review done in 2005 that compared the two between post-void residual measurements and catheterization. And notice that they're actually pretty similar for most of the generalized patient. This is actually both men and women in this study here, except that there's about three to eight times more for the bladder scan ultrasound. But as most people are probably on this webinar here, we don't have typical patients and we're seeing people for specific conditions. And so let's delve a little bit more deeply into that. And so specifically for prolapse, is it accurate for prolapse? This was a nice study that was done in 2020, single institution, and they looked at 87 women with mild to severe prolapse. And when they looked at then comparing the ultrasound to the cath volume, it was very interesting. They noticed that it was pretty close when it was less than about a hundred milliliters, 97, 94% were pretty close, but it was 73% when it's greater than a hundred milliliters. And so then when they did the analysis, their regression coefficient, mild prolapse was close to ultrasound and catheterization were similar, but advanced prolapse, you start to lose some of this coefficient. And so that's something to keep in mind when you're looking at that number and you're doing it, keep in mind what could be potentially changing that number and affecting the way that you're diagnosing or understanding how much is left in the bladder after voiding. And so why does this happen? Well, I think that a way to think is, is that again, that calculation is that you're assuming a sphere. And so you can see here on the right, the assistocele, it's measuring a sphere and it can calculate again. A lot of the bladder is actually outside of that sphere. And so that's going to impact on its ability to measure accurately for it. Another thing that can keep in mind if you're getting different numbers is, is a person has large bladder diverticulum, it's not averaging those together. And so that there's really a potential for some loss of, of accuracy with this. And so again, kind of keeping in mind what the number is, how it's collected and how you're interpreting it is very important. And so again, assume an ellipse configuration, it's not accurate. Also another thing to mention, if a person has a large amount of ascites or peritoneal fluid, it also will be inaccurate. I think my recommendation is that if you're unsure about the accuracy of a post-void residual, just perform intermittent catheterization. It's easy to do. You'll be able to correlate. And I would trust the intermittent catheterization number was more validity than the ultrasound scan for the most part. And so let's talk a little bit about what is a normal post-void residual. I think that number gets thrown around and it's very difficult to kind of peg to a specific patient sometimes in a specific volume. This study was from 2008 and they looked at 1140 women who presented for a gynecologic exam, general exam. And what they did is they looked at the volume for post-void residual and 76% had a zero to 10, and then a gradiated amount between 11 and 30, 31 and 50, 51, 100. And then rarely did people have more than a hundred. So it tells you a little bit about the population that's being seen here, mostly younger women in this study. But I think what was interesting about this was that they can really kind of peg as a rough number of people say, well, what's a normal number? According to this study, about 85% of women have less than 50 cc's in their bladder afterwards. I think this is important because people tend to look at it's either zero or you're in retention or you have some degree of post-void residual. I don't think that's accurate. And I think that it's normal to be carrying around a small amount. And this has a lot to do with how efficient your bladder is working, conditions in which you're avoiding in the toilet, whether or not people are rushing you. And so 50 cc's or below, I would consider kind of a good number to keep in your mind is that's roughly normal for most people. So let's talk about what is chronic urinary retention. We have a lot of different ranges that this covers. So we can have somebody with chronic urinary retention who is completely asymptomatic. In this example, a patient is discovered on CT scan and otherwise doesn't have any symptoms. People can come in complaining of lower urinary tract symptoms and notice that they have a very large residual left in their bladder. And some people even in renal failure, the cause of renal failure is chronic urinary retention. So there is a wide range of severity of symptoms associated with this. And if you look through the literature, there actually is not a society-endorsed definition of chronic urinary retention from a historical basis. It's mostly defined through the literature of what people were doing studies from. And if you look at the literature, it ranged tremendously as to what number they used for that. And it was between 100 and up to a liter in some cases. Most importantly, chronic urinary retention is usually described the most in men. It's less commonly described in women. And more in men because of BPH. And so because of this, there really isn't a widely accepted treatment algorithm that's been endorsed or validated with multiple years of observation or research. And so good thing to keep in mind is that all treatments have potential morbidity. So it's a good idea to kind of think about how we want to think about this condition. And so because of this wide definition of symptoms, no standardized method of approaching In 2018, the AUA pulled together a chronic urinary retention working group to kind of put some framework around this, to come up with a definition and to propose a treatment algorithm. I was part of that group. And we used the literature based on an AHRQ report that was all the evidence on chronic urinary retention based by PICO and specific criteria. And that was supplemented by additional literature that the group thought was going to be valuable to supplement the definition. And so this was really, this working group created a definition and treatment algorithms really based on this review of current literature and expert opinion. And for those of you familiar with the different techniques, we used the modified Delphi technique to come to consensus that has the most validity for when you have kind of non-standardized reports. So the white paper had four deliverables. One was to make a reproducible definition of chronic urinary retention that could be applied to index patients. And then we wanted to be able to characterize both men and women similarly. Third, we wanted to propose a treatment algorithm for these index populations. And then lastly, we wanted to be able to have endpoints to be able to tell whether or not these treatments were effective for people. And so with this in mind, the chronic urinary retention working group wrote a white paper published in 2017. Sorry, group was in 17, published in 17. The definition of chronic urinary retention based on those criteria was that a person would have an elevated post-fur residual greater than 300 milliliters. It was persisted or presumed to persist for at least six months. And so based on multiple observations or measurements, and it's documented at least on two or more separate occasions. And this differs from acute or transitory urinary retention. And we'll talk about that in a couple of minutes and exclusions with this, which are important or chronic urinary retention related to neurologic or oncologic sources. I think that's a different group of people. And so we're talking about non-neurogenic chronic urinary retention for this definition. So a big question we always get asked is why 300 milliliters and why six months for this diagnosis? And, you know, the, the, the answer really is, is that somewhat arbitrary, to be honest, I was based on the Delphi method and expert conclusion, but it had framework and there was some reasoning behind this. The six month was really because that the observations your post-forward residual can change. And we've all seen that people, whether or not it has to do with time of day, whether it has to do with time of day that you're having, you're measuring the residual, what you're doing, whether or not the scanner is accurate, all those different things. But this study, I thought caps encapsulated this dilemma somewhat well, and they looked at close to a thousand women and they noticed that less than 200 milliliters, the number fluctuated much more considerably. And that was within a two year measurement for it. And so the idea that 300 is maybe a much more, much more durable number than something that is of less volume, such as 200 or 100. The second thing is 300 does have a little bit of some scientific basis around it. And then some animal, animal models above a kind of a simulated 300 volume in humans extrapolated based on the animal model, there seems to be some change in bladder perfusion. And the idea is, is that the more full that the bladder gets, the more ischemia is going to occur at 300 is kind of a, a rough back of the hand measurement that, that can apply to humans. And so based on these kind of two different factors and plus expert opinion, that's how 300 milliliters and in six months was ultimately settled upon. And so we talked earlier about incomplete emptying. So, so what is an incomplete emptying and how is chronic urinary retention different? Well, incomplete emptying is really the subjective sensation that the bladder doesn't feel empty. And this was defined by the international cotton society back in 2010. And I think it's important to differentiate between the subjective feeling and an objective measurement because they don't always correlate. A nice study in 2018 showed that in 138 women, post-void residual volume was really only pegged or, or, or as associated with symptoms of terminal dribbling and slow stream. The intensity of urgency and frequency is not always associated with the volume that's behind. And so incomplete emptying can be a, is more of a sensation. Whereas chronic urinary retention is really more of a measurement. And I think that's how it may be separate those two. And again, this separates directly from acute urinary retention. Acute urinary retention is very different than chronic urinary retention. As, as people know, this is something that is associated with a strong urge. There's a full bladder and an inability to avoid despite attempting multiple different times. And this is from the JAMA open network. It's just an algorithm that was published on acute urinary retention, essentially patients presenting with the symptoms of persistent urge, fullness, bladder pain, a bladder scan is done. And if they have greater than 300 milliliters, then a catheter should be placed to be able to decompress it. I think it's important to measure many times because sometimes people can have the same symptoms of need to avoid fullness pain. And it may not be an infection. It could be a, it could be a stone. It could be people have constipation. It could be interstitial cystitis. So I do think the number of measuring is important to document that there is urine in the bladder and the person is unable to avoid. Okay. So let's move on to diagnosis here. So the causes of urinary retention, really two big groups, you have bladder outlet obstruction and you have underactive bladder. Chronic urinary retention lives in both of these worlds. I think that you can have chronic urinary retention from outlet obstruction where you just can't get the urine out, or it could be that the bladder is underpowered. And so when you're looking at somebody who has an elevated post-void residual meets the definition of chronic urinary retention, think about these two big causes, outlet obstruction, underactive bladder. What do I do when I, when I see this? One of the first things I like to do is look at the medications and going, this is a common list of things that can cause them. And the one that people most commonly associate with are anticholinergics. And many times the context that you'll see these patients with elevated post-void residual, they are treated for symptoms of urinary frequency and urgency. They're given an anticholinergic and it became much worse. And so that's a good thing to keep an eye out for. But other things also may be a less commonly known that can be associated with it. Tricyclic active depressants, that works by the anticholinergic effect. Beta adrenergic agonists, that turns on the beta-3 receptors within the bladder and it promotes retention. Calcium channel blockers, I'm not sure we understand the complete mechanism, but it may actually have to do with some of the TRIP receptors within the bladder. And that's a target that some people have been looking also for overactive bladder. I got to admit, I'm not sure I know the anti-steroidal, anti-inflammatory effects from it. That's something that has been reported. I'm not sure I understand the mechanism. Other things like opioids and benzodiazepines are also commonly known. You tend to see those in people who have been treated for chronic pain or post-operative who have persisted and taken these medications for a long time. And so thinking about the physiology for it, you know, big list. And it's good to kind of keep things in mind a little bit. And go through a couple of these that I think are important to highlight. In women, obstructive prolapse, we all know that this can cause urinary retention. And things that also can be obstructive can be things like lichen sclerosis. The one that I always point out to our residents and our fellows is that herpes simplex virus also causes retention. And what's common about all of these? They're really, they're diagnosed by a physical exam. So I would advocate strongly that if you're working somebody up for retention, this is something that they need to be seen and a physical exam done. With the advent of telemedicine, I'm a big fan of telemedicine. A lot of different things can be accomplished with it. I'll make the argument that when you're working up somebody with chronic urinary retention, a physical exam is crucially important to be able to start thinking about what some potential causes of this are. And so what's my assessment for chronic urinary retention? Document the symptoms and more about that later as to why I think that's important. I like to make sure we have a good history on constipation and I look at the medications. Supplements are also important. Sometimes we don't really know what's all in the supplements and I think that's always a target to have people stop if you're not familiar with what it is. Also, I like to ask people about amphetamine use and opioid use too, because also can cause retention. From a past medical history, I always like to make sure if somebody is a diabetic or has a neurologic condition, you've identified that and then understand what past surgical history that they've had. I'll order then a metabolic profile and a renal ultrasound when I suspect somebody is having chronic urinary retention. And again, why we do that a little bit more later. I like to do a very brief neurologic exam. I think this is intimidating. It is to me sometimes too, but when you really break it down, it can be done within five minutes really. I think covering the major areas of that affecting the urinary tract. Memory, it's kind of thinking about cortical function. I just give them three items, five minutes. I like to look at the cranial nerves to make sure that there's good association, circulation within the brain. Sensation to light touch. There's the dermatomes you can see listed there. I make sure that they can just flex and extend. Tandem gait I think is really helpful to be able to see whether or not somebody is affected by the way that they're walking. They can affect the way that they void. And then I like to do a Romberg for balance just to make sure that we don't have some cerebellar issues. It seems like a lot to do, but it can really be done quickly. And I think it's helpful to be able to understand a little bit of what people's baseline is. So we're wanting to get into the weeds a little bit. Why does this happen? You can kind of think about maybe three different pathways of what can cause an elevated PVR. For bladder outlet obstruction, what the model people think it is, is is ischemia. And so what's happening is, is that the bladder is obstructed. The extracellular matrix is getting replaced with usually type one to type three collagen. And the bladder is becoming less flexible to some degree. It's stretching, but it's not able to contract because the extracellular matrix is being replaced. And so that's the thought of the model of a bladder outlet obstruction. There's a pure myogenic hypothesis, meaning that there's something challenging within the myocytes themselves. People think, excuse me, that that could have been a distention injury. People have got their bladder is just too full. Myocytes, the trucer muscles pulled apart, not able to contract sufficiently. And so there's a myogenic hypothesis. Pardon me. Sorry about that. The another option is to be thinking about is the neurogenic hypothesis. And this is that the myocytes still, that a trucer has the function to contract, but the on off switch isn't working. And so the trigger to be able to store or empty is not being flipped. And so when we're thinking about chronic urinary retention, it's helpful to think a little bit about what may be driving it. You know, what are we thinking about with this for the options or for the causes of it? And so neuro-urology in a slide, I like to kind of think a little bit about what's happening and why do we think you're having the, why do we think we're having these symptoms? And so I think there's maybe three ways to be thinking about the whole neurologic symptom. We can think about, this is the trucer function, kind of the red box there. This is a bladder issue. We can think about it's a kind of peripheral nerve communication issue. And it could be that the afferent nerves running through the pudendal and the pelvic carrying A-delta and unmyelinated C-fibers have been impacted. And so you've lost sensation of the bladder. This is a target of diabetes and you tend to lose a lot of sensation for it. Could be part of the autonomic nervous system in which the sympathetic nervous system which promotes bladder storage has been affected or the parasympathetic nervous system which promotes bladder emptying. You know, colorectal surgery many times affects the pelvic and the pudendal nerve affecting both the afferent and the parasympathetic contractility of it. So thinking about, is this a communication issue of the peripheral nerves? The final big box is that, is this a processing issue? So once it gets to the spinal cord and it comes in at the sensory, comes in towards the sacral nerve roots, spinal thalamic track is activated, goes up to the brain and the brain is telling, the cortex is telling the Ponting-McDurish complex either to be inhibited, so it's promoting storage with the sympathetic nervous system turned on or it's the inhibition is lifted and the parasympathetic nervous system is turned on and the bladder empties. And so think about bladder problem, peripheral nerves or is this kind of a central processing issue? I think the area that we're learning the most about retention actually is the level of the brain. The mechanical stuff of the peripheral nerves, I think is pretty well understood, but at least in terms of an injury model, but how people are processing sensation from the bladder I think has a lot to do with understanding retention. And so to get into a little bit deeper here, when the afferent nerves are carrying the messages up the spinal cord, it hits the periaqueductal gray area and this is a way station for processing. So the periaqueductal gray communicates with the Ponting-McDurish complex with a tonic inhibition signal, so it's always inhibiting it. But as the bladder fills up, all the signal goes through the other parts of the brain interpreting how full the bladder is. So it's putting it through the anterior cingulate cortex that monitors the level of stress that you have, the lateral prefrontal cortex, time, space, emotions, the medial prefrontal cortex is putting in things into social context. And so as a signal is hitting your brain, the cortex is processing it and letting you know when it's socially appropriate to go to the bathroom. When you reach that level, then you get a signal to go to the bathroom and then the inhibition signal is lifted from the Ponting-McDurish complex. And I think this is an underappreciated source of chronic urinary retention. It's just that the brain isn't processing the signal from the bladder correctly. And so neurologic symptoms that are associated with chronic urinary retention, spinal cord, most people are familiar with that, it causes atresia, sphincter, and disnergia in a contractile bladder, multiple sclerosis, you can see both obstructive and underactive, spina bifida, all those are kind of at the level of the spinal cord. The stroke can cause retention, particularly if it's the posterior circulation that's affecting that periaqueductal gray and the Ponting-McDurish complex. If the signal to be inhibited is never able to be lifted, you're stuck in retention. Transverse myelitis is at the level of the spinal cord, Guillain-Barre, arguably a neuromuscular junction that's also a potential source. Multiple system atrophy, to be honest, I'm not really quite sure why it always causes retention because Parkinson's is less commonly associated. It may have to do with the substantia nigra and the amount of acetic choline available in the body. And so your dynamics may be needed to differentiate underactive bladder from obstructive physiology. And this is a great tool if you're not really quite sure. Just a rough example from our institution, we looked at a group of neurodynamic studies, 30% were from underactive from obstruction and 35% of the people had a change in surgical plan after doing these studies. Neurodynamics can really be helpful for you to get some guidance on what's your next step to be able to help and treat people. What are we looking for in neurodynamics? Well, we're essentially looking for underactive bladder of an acontractile bladder where you can see that the P. detrusor is not generating any force here. The person is voiding by abdominal pressure that's being generated from the abdomen as pushing into the bladder. This is typically people will describe Valsalva voiding as a way to be able to empty. There is a urodynamic definition of underactive bladder and there's kind of three big major groups of ways that people think about this. There's the bladder contractility index, which is the calculation of the P. detrusor at Qmax and then there's an addition with that. Rough number, if you're remembering numbers less than a hundred bladder contractility index is underactive. And there's a nomogram of kind of high flow, medium flow, low flow pressure based on that. Again, the detrusor pressure at Qmax as the Schaefer nomogram. Then there's the Watts factor, which is again, trying to measure how much power per surface area. Frankly, I find this less helpful in women. In men, it tends to help a little bit with degree of obstruction, if you're looking to do some type of outlet procedure. In women, I find this less helpful and almost all these data is validated in men as opposed to women, but this is the formal definition. Again, harp on this is that urodynamics is assuming a spherical shape. So if you're looking at pressure within the bladder, you're assuming that it's all within a spherical shape based on Laplace's law. If you have something where somebody has a lot of reflux, a reflux, if there's a large cyst to seal, pressure may be off and something to take in mind. And so you may be underestimating pressure and the contractility of the bladder. I'll spend a couple of minutes just on to think is an important finding on urodynamics and associated with neurologic diagnosis. Detrusor sphincter dyssynergia, I think is something that we should be on the lookout for. You can have three different presentations of it. And what it is, is when the detrusor muscle is contracting, the sphincter muscles are not relaxing. And so you can get increased EMG activity during detrusor contractility, which you see on the urodynamic study on the CMG. You can see increased pressure if you're measuring just in the urethral profile pressure, or you can see it on a VCOG. Roughly the different pieces here, urethral pressure here, you can see this is where there's a sensor in the urethra. You have a spike in urethral pressure. The EMG, you can see here is that as the bladder is contracting, the EMG is increasing in activity. And these are classic findings in urodynamics of detrusor sphincter dyssynergia. This is a classic cystogram, voiding cystogram, dilated proximal urethra. It's pegged right here at the external sphincter that's not relaxing. And this is people's over time can start to form a Christmas tree bladder. And there's a lot of room, I think, to be able to look at this further. Right now we use detrusor sphincter dyssynergia as a yes, no answer. Do they have it? Yes or no. We've looked at Michigan as to whether or not we can look at this as a continuous variable. And on some of the studies, we looked at MS and spinal cord injury patients, roughly people who have a greater than 20 centimeter change of pressure in their sphincter when you're trying to void. It's pretty close to pathognomonic of detrusor sphincter dyssynergia. Tends to be if things are longer. We saw that more in men. And longer episodes of detrusor sphincter dyssynergia tend to have a higher bladder capacity. But I think we're trying to understand a little bit more of degrees of severity for it. And it's really difficult because you can see there's a big scatterplot for it. I think we can establish a floor, but we're really struggling to see whether or not higher pressures are associated with different outcomes or different symptoms. So hopefully more to come on that. And so now we'll get onto treatment is maybe the most important part of all of this here. So as part of the work group, what we did is that we thought chronic urinary retention can be stratified into risk. And so the first big group you wanna look at is high versus a low risk population. And so a high risk population were people who we thought would be have harm to an organ system because of chronic urinary retention. So that would be something like hydronephrosis, bladder stones that could cause infection, people who had renal failure or a decreased GFR, people who are having recurrent urinary tract infections, all those who are considered risk factors for harm for people over time. And that would place them in a high risk group. The next big group that we're trying to stratify is symptomatic versus asymptomatic. So symptomatic chronic urinary retention was really people who are associated with moderate to severe urinary symptoms that really would advocate using questionnaires to be able to track over time. I think it's really helpful to be able to kind of measure severity. I think also people who are symptomatic would be having a history of catheterization within the last six months. And this is excluding acute or transitory retention. This is people who just needed to catheterize persistently to empty their bladder. And so based on this, we kind of developed this two by two table and for low risk asymptomatic people, we make the argument that these people don't necessarily need to be treated. If somebody is high risk, absolutely they need to treat the risk and so draining the bladder and be able to kind of address the safety issues. But for people who are low risk and asymptomatic, we can make an argument that these people can be followed. For symptomatic people, I think for low risk symptomatic people, you can target the symptoms specifically and try and treat as much as it bothers. For high risk symptomatic people, address the risk first and then work on the symptoms afterwards and stratify by that. So what we like to do is to help understand risk by getting some of this information. That's why I said in the beginning, I do like to get a upper track imaging and I do like to get a metabolic profile. In addition for severity, I do like using quality of life instruments. Again, for risk, treat the risk until it's improved. For symptoms, treat the symptoms until improved or tolerable and then you monitor for changes over time. This is the algorithm that's in the white paper that we published and the key here is is that these are patients that you follow. And so patients who have had they're not being treated for their symptoms, the low risk, minimally symptomatic people, those people should be assessed roughly yearly to be able to make sure there isn't changes in risk for them. Or if there's any episodes that move them from a low to a high risk or from a asymptomatic to a symptomatic group, those are the people that you need to then treat. So moving on here, what are our end points for chronic urinary retention? And so I think symptoms improvement on validated instruments are important and that's how we know whether or not the symptoms are actually getting improved. Another end point for treatment is that they don't have to catheterize anymore. I think that's a really big one and it's taken mostly from the male literature but also can be applied for anybody is a successful end point of chronic urinary retention is that they no longer need to be catheterized. And then also that the risk has been addressed. So somebody's urinary tract infections, those are resolved. Hydronephrosis, that's resolved. And I think importantly, that it's not just a one-time treatment but these symptoms and risks are stable over time. So it's a durable result. And so those are the end points. Medications is a good way to think about treating most things but unfortunately we don't have a lot of medications that can affect chronic urinary retention. I'm gonna argue against Spethatocol. Cholinergic agonist, it has minimal sustained efficacy. There is almost no literature that supports that it works. Everybody has patients where they take Spethatocol, it seems to work, they do great. But if you look at the large group of people, there's very, very little evidence that suggests that Spethatocol actually works. And so the more associated with people getting kind of pro-cholinergic symptoms in the GI system, things like abdominal pain, nausea, a lot of people get tired. So the white paper, and I make the argument that Spethatocol is not a good treatment for chronic urinary retention. I like alpha blockers and there's a growing body of evidence to show that. There's a randomized prospective trial from 2010, women were given Tamselosin and 86% had some improvement in PVR and quality of life. There's here it says, there's no difference in improvement from obstructive, non-obstructive group as to who improved. But symptomatically, the people who had elevated post-void, I'm sorry, from the people who have an elevated post-void residual are symptomatic. Chronic urinary retention as a whole seem to benefit from alpha blockers. What about intermittent catheterization? Who should you treat and how much? I think, you know, this is again, treating as much as it's a safety issue. You probably want to be more aggressive of using intermittent catheterization to a safety issue. For a quality of life issue, maybe more specific for a symptom that you want to be addressing. People with an elevated post-void residual who have nocturia, sometimes catheterized before they go to bed can be a good option for treating that specific problem. The goal though, should try to keep the volumes in the bladder lower than three to 500 during their symptomatic period. And so I usually say, if you're thinking total four times a day is usually adequate for people. What about what type of catheter? We did a systematic review looking at this and the data is not really very clean. And so it's difficult to tell sometimes, but in general, the trends are that a hydrophilic catheter has less UTI risk. There's a good study, meta-analysis that showed that probably reduces the risk a small amount compared to people who are using a non-hydrophilic catheter. Sometimes these are more expensive. Sometimes you need to document additionally in the chart to be able to do it, but hydrophilic may be beneficial. How do you choose a catheter though? This is an algorithm my nurse, Lisa, you and I kind of developed as part of our previous paper, I like to think of it as kind of a cloud. And so you think about a catheter selection, there's all these different things orbiting around and kind of the sky, and you need to kind of weigh the relative intensity of each one of them. And so if somebody has a latex allergy, it chooses a certain type of catheter, insurance may dictate it, but what the people like to do, how much education support they have, how are they gonna be able to use this? What's their infection risk? What's their body habit is? So all these things are kind of processing. And when I talked with Lisa about this, originally we were thinking I wanted to make a checklist, but she said, I do all these things simultaneously as kind of as a processing, looking at it like the sky. And so I think that's a good analogy that she came up with is thinking about just a cloud selection of catheter based on kind of what's jumping out at you is gonna be driving these selections. So a word about intermittent catheterization, not without risk. And so really important to kind of keep this in mind. So please, the MS population study that we did here is to kind of highlight this. So we had a group of MS people that had elevated post-flood residuals. Some were treated with alpha blockers, some were treated with intermittent catheterization. People who did intermittent catheterization, seven times greater risk of having at least one or more UTIs afterwards. Yes, MS is immunosuppressed population, a little bit more risk for infections, but intermittent catheterization absolutely can be driving infection risk. So please keep that in mind. So managing chronic uterine retention after urethral sling, kind of very specific to the urogynecology group here. Two different big categories. I'm thinking, is this bladder outlet obstruction or is this an underactive bladder? If somebody has a bladder outlet obstruction, you know, then this is chronic, again, more than six months, multiple post-flood residuals. I would do an alpha blocker first and then try urethralysis. If it's an underactive bladder, I'd start with intermittent catheterization first to help decompress the bladder. And then if they have sensation, they feel like they need to avoid, but they can't at physiologic volumes and think about neuromodulation. And this is again, differentiated by urodynamics based on the diagnosis. So what about urethralysis for chronic urinary retention? Very little data on this. So it's almost all on the relatively post-operative, immediate post-operative phase. Studying this after six months, I think there's not a lot of great data. I pulled this study from 2003. They reported very good results in 24 women doing aggressive urethralysis. They reported only roughly 20% had new stress incontinence. You know, you should present your own data. We looked at this, some sling or visions for us, and about 20% of people still had persistent obstruction despite an aggressive urethralysis. You know, stress incontinence for us was a little bit higher than 20% also. So I think it's a feasible thing, but a lot of counseling really needs to go into this to talk about their expectations if you're gonna try an aggressive urethralysis. Sacral neuromodulation, a great option for people who are not obstructed. It's upregulating the sensory fibers. So if you remember our diagram, upregulating the A fibers, downregulating the C fibers, and it's flooding the signal up to the periaqueductal gray area. So it's an amplifier. I think cognitive impaired people, the amplification may not be high enough for them to be able to kind of recognize it. So a little caveat there. And again, going back to our map here, what it's doing, it's amplifying the signal. So now this signal that's being from the bladder fullness is actually being interpreted by the brain, and you're able to turn off the inhibition of the pontine lictorice center. How effective is it? Some studies in the past kind of mixed methods, a little bit difficult to tell, but roughly somewhere around 50 to over 80% of people responded to it. Those are highly selected groups, and their definition of success was, I think, maybe overestimating the efficacy a little bit. The study that I anchored to is really this one, just published in 2023, Netherlands Collective, 215 patients. Difference is they ran their study for four weeks. So the first stage was implant for four weeks rather than the typical two we use in the U.S. And they had 62% successful. I thought that was a good number to kind of think about and a very good study. Younger patients did better. And interestingly, patients who had psychiatric illness, including PTSD, did better. And again, I like to think that this is amplifying the signal and allowing the brain to be able to clarify better. And so, I think these are good things to think about. Posterior tibial nerve stimulation, very little data. There's four trials, three are from one center. They also report about 65%. Anecdotally, I tend to think it's not as effective as sacral neuromodulation. We need to study it, but maybe something about having continuous stimulation as opposed to this intermittent stimulation that makes a difference. What is if nothing works? Suprapubic tube is helpful for some people. It's changed every four weeks. Suprapubic tubes can certainly increase the risk of UTI and bladder stones. And just key point, the drainage bag needs to be lower than the bladder. How do we put it in? I prefer the retrograde approach in which you insert the catheter, the sound into the bladder, tent the bladder up against the abdominal wall, make a little incision, pull the catheter in, and then cut the stitch and pull the catheter back into the bladder position. Less risk of button-holing into the peritoneum this way. Antegrade approach, better for people who have higher BMIs just because the sounds, many times you can't reach the abdominal wall, but also a higher chance of misplacement with it. There is actually something called a belly bag. This is something that some people don't wanna wear a leg bag for. To be honest, I'm still struggling with the physics of this one. It seems to work. It doesn't back up into the bladder. They say that the thing needs to be lower than the bladder. I think this works more by siphon and it kind of allows it to drain. But this is the only bag that I would suggest that be kind of worn up around the waist as opposed to the standard leg bags. Some novel technologies are on the horizon. There is a intraurethral pump that has been developed in Europe, studied. You put it into the urethra. It's a little motor that you have a magnet that you put over your pubic symphysis that turns on this little fan that blows the urine out. 50% of people tolerate it. It needs to be changed every 29 days. I'm still kind of looking at the US trials and the efficacy for it. And a lot of displacement of it. But the concept is neat to be able to think about. It's something that's actually pulling the urine out as opposed to you need to catheterize. I pulled this from clinicaltrials.gov just to kind of get an idea where a lot of the research is. It's really neuromodulation. People are really looking at how can you tweak the communication either at the level of the peripheral nerves or the spinal cord to be able to amplify the signal to the brain. And I think that's where a lot of urinary retention treatments are gonna be refined in the future. So let's go back to our index patient to finish up here. This is your 58 year old woman. Frequency, she had reports, doesn't feel empty. She had a slow stream. She has voiding and her PVR was 300. So what do you think this is? Nope, I should have said she came back six months later and still had a PVR of 300 cc's. But if this is a persistent symptom and it's been documented several times, then she has chronic urinary retention. So what would we do with this? I would work on first fluid management and time voiding kegel exercises. I would start an alpha blocker for this person. And if they didn't respond and we didn't have any additional safety issues that we evaluated and found, then what I would do is evaluate them with a urodynamics to determine if this is underactive or obstruction and try and treat accordingly. So some take-home points, stratified by safety, by quality of life issues. Diagnosis is clinical. You want to be able to kind of measure the volume with it and peg to their symptoms. The urodynamics is really only there to confirm outlet obstruction versus underactive bladder. I like alpha blockers for pharmacologic treatment. Unobstructed underactive bladder does respond well to neuromodulations, keep that in mind. And catheterization remains an option, although with risks. And so thank you very much. I appreciate giving the opportunity to talk to everybody about this and I'm happy to answer any questions. Thank you so much, Dr. Stoffel. Now it's time for our question portion of the session. So as a reminder, if you haven't already, please use the Q&A feature in the Zoom webinar to ask questions. I'll get us started with the first couple of questions. The first is, is the Schaeffer Nomogram specifically used for urodynamic definitions of underactive bladder or obstructive voiding? And could the Blavis-Grouts Nomogram be used as well? Yeah, it's a great question. The Blavis-Grouts and the Schaeffer Nomogram are variations on, it's kind of how you're looking at the axis of it. They're using the same P. detrusor and Qmax calculations of it. I struggle a lot with these nomograms because you really need a strong, clean urodynamic study to be able to do it. And really a lot of this data was validated in men who have a prostate in which you have a clear differentiation sometimes between high pressure, low flow, and really no pressure with it. It's harder I think to interpret in women and absolutely I think these can be used, but I think you need to match the clinical symptoms and I think you need to see the traces rather than just look at the calculation to see if it makes sense, particularly in women. Okay, for our next question, the participant asks, I've had many patient who reports urethral dilation by urology in the past. Any thoughts or evidence that you're aware of about this if there's no true evidence of stenosis in terms of urinary retention? Yeah, I think there's always been kind of a dilemma about it that people come in every few months, they have their urethra dilated and they avoid better. I think what, so one of the theories on it is is that what kind of happens is the dilation in itself is actually causing little micro trauma that is you're breaking up again then as you're going further down the road. And so the dilation that you're doing is probably maybe even treating an iatrogenic issue that you've created with some of these chronic irritations that you're giving. From a mechanism standpoint, for somebody who has no obstruction, I think what you're actually, maybe what they're trying to do is see pelvic floor tone. And I've always wondered as to whether or not what they're trying to, when you see that there's no obstruction, but they're trying to dilate, they're actually trying to help facilitate in women's this pelvic floor relaxation with it. Because when you're doing the dilation, they're always telling people, relax, relax, I'm gonna put the sound in. And I'm wondering if you're just trying to drive some pelvic floor relaxation. Don't advocate urethral dilation because I don't understand the mechanism as to why that would work in somebody who doesn't have clear scar tissue or an intrinsic obstruction within the lumen. So it sounds like for someone like this, you'd recommend pelvic floor physical therapy? I would, I think it's much more effective. Okay. And the next is what stage of anterior prolapse would you attribute significant retention due to prolapse? Yeah, I mean, I think it's a great question because I don't always know that how much, to me, the mechanism is that the urethra has to be hinged. And so there has to be enough, a downward force to be able to be kinking the urethra. That's a great question actually for John Delancey or Mary or somebody like that, because I think it probably depends a lot on urethral support too. Because the urethra and the urethra needs to kink and how much of the movement there is, is probably predicting it. And it doesn't make sense to me that people who have high grade prolapse don't have any retention. They're emptying their bladder fine. And other people who you wouldn't expect them to be in retention, but their postpartum residuals are a lot elevated. So I don't know if degree of prolapse is predictive of amount of obstruction, but certainly there's some relationship that some women who have prolapse, it has driving obstruction. So a great non-answer. I don't have the answer either. Maybe Dr. Delancey would. So back to our index patient, would you discuss intermittent catheterization or just the alpha blocker? And then what if her PBR was 400 and not 300? That's a great question. And I think that some people want to just get better as fast as possible. And if somebody is really symptomatic, you think they're having overflow incontinence and it's just driving their quality of life, they start intermittent catheterization. They'll get better very quickly on that. And so I think to me, it depends on the degree of severity of their symptoms. And so people who I think have very high post-forage residuals, very symptomatic from it. And again, we're just talking about the quality of life people here. I give them both options with maybe steering them towards intermittent catheterization because I think that it may get them better faster. If these symptoms are annoying, but they're living with it, I think an alpha blocker probably has a higher, people will stay at it longer rather than the intermittent catheterization. How do you sort of sell intermittent catheterization to patients? I think a lot of patients come into our offices and they're like, you want me to do what? You want me to do this more than once a day? What's your approach? I think what I try to sell it a little bit as a way to heal the bladder. So I kind of anchored to that number that less than 300 CCs is a good physiologic number. And so if your bladder is, so somebody has 600 CCs in their bladder and it's really difficult for them to be getting, to have their bladder regain its contractility if they are always carrying a standing volume of five, 600 CCs. And so I almost sell it as a rehab for the bladder and say, look, we're probably, you don't think you're going to be doing this your entire life, but we need to keep those standing volumes down to allow those detrusor muscles to grow back together in order to kind of promote more contractility. And so more severe symptoms, I think we try to try to get them on that, higher volume, more severe symptoms, trying to get people on that sooner rather than later. And are your clinic nurses driving a lot of the teaching and like getting your orders, your durable medical equipment orders? How's that working for you? Yeah, no, great question. I think it's a whole process and the whole appealing for insurance companies, the whole system is very challenging to be able to do. Our nurses are the people who do that for us. And they come in, they do the teaching. We usually give them like two or three different catheter samples to try and see which one do you like? And then they go home, they try it, and then they give us a call and we order that for them. But yeah, it's almost a visit, excuse me, in itself. It's really a lot of time. Do you have any tricks on making sure that you obtain insurance approval for your catheters? Yeah, no, great question also. What we do is document the diagnosis. And so catheters will be prescribed for urinary incontinence in general, but also for urinary retention. And then they will get covered if you specify the amount of times you catheterize per day and the type of catheter. And so I will say, you know, 14 French catheter, and then a specific brand if we find one that they like, patients to catheterize four times a day. And that speeds up the process a lot. If you just order a catheter, they won't fill it because most insurance companies are moving now towards single use catheters. And so they'll send people a box of the number of catheters that you prescribed for that month. Speaking of single use catheters, what's your opinion on washing a catheter and ever reusing it versus truly just single use? I have tremendous concerns about the environmental impact of a lot of these catheters. And, you know, I have some people, you know, six, using six catheters a day, you know, 365 days a year. This is just a tremendous amount of non-biodegradable material. I think that washing catheters with clean technique and letting them air dry, absolutely, I think you can reuse them. Our European colleagues will, you know, clutch their pearls and say that that's, you know, that's just not done. But the data actually shows that. And in this analysis that we did, multiple use catheters actually don't have a higher use, a higher risk of infections in a lot of these studies that are shown. I think it's a tough sell sometimes. I think, you know, people don't want to carry a catheter to work and, you know, wash it out in the sink and then, you know, have to come home with it. So there's a convenience factor. But yeah, I actually think reusing catheters is okay for the most part. We probably have time for one more question. This comment says, thank you so much for the amazing talk. How can external modulation help in your, neuromodulation help in your opinion? And what would that mean? I'm sorry, can you repeat the question? Oh, sure. How could external neuromodulation help? External neuromodulation. Yeah. Yeah, so things like TENS and other, I think there's a lot of work that could be done in that. The TENS tend to be very broad. And so I'm not sure that we're always targeting the right area, but anecdotally the neuromodulation, a lot of it is based off of acupuncture studies that done, you know, hundreds of years ago with the idea of meridians. And there was a bladder meridian that's very close to the ones that we try to stimulate. So I do think it just has to do with accessing the nervous system correctly. I agree. I think that there's going to be improvements in this and transcutaneous stimulation may be a really viable way if we have the right target and the right delivery system. All right. Well, on behalf of the Oggs Education Committee, I'd like to thank Dr. Stoffel for this excellent webinar. Please consider joining Oggs for the 2025 coding webinar on March 12th. And also be sure to register for our upcoming Oggs Education webinar on March 19th with Dr. Yahir Santiago-Lostra, as she presents a webinar entitled The Diagnosis and Management of Lower Urinary Tract Symptoms and Multiple Sclerosis, Parkinson's Disease and Spinal Injuries. Remember to follow Oggs on Twitter and Instagram and to check our website for information on all the upcoming webinars. Thank you all so much for joining and Dr. Stoffel for being here and we hope you have a great evening. Thank you so much. Take care. Have a good night. Good night.

chronic urinary retention

Neuro-Urology

Pelvic Reconstruction

diagnosis

management

urodynamic studies

alpha blockers

intermittent catheterization

neuromodulation

sacral neuromodulation