Case Studies in Urinary Tract

1. Case Studies in Urinary Tract/Bladder Dysfunction

2. Case Study #1

4. Case Study #2

6. Case Study #3

10. Case Study #4

13. Case Study #5

15. Case Study #6

17. Case Study #7

20. Case Study #8

23. The patient underwent cystourethroscopy to evaluate her bladder tenderness, nocturia, urgency, and frequency. She had cystourethroscopy with a fill and refill study to a maximum cystometric capacity, in the supine position, of 275ml. As the bladder filled it was obvious that the patient was developing a detrusor contraction with a trabeculated appearance to the bladder that was not noted on initial examination at lower volumes. While there was no leakage at this volume, the patient�s bladder neck was noted to be intermittently funneled, when the patient complained of severe bladder spasms and suprapubic discomfort. On further questioning it was clear that the patient had these symptoms at least once or twice a day at home.

24. Standing subtracted cystometry revealed escalating phasic involuntary bladder contractions ranging from 25 to 75 cm H20. The detrusor leak point pressure was 75cm H20. Endocoscopy revealed mild erythema along the length of the urethra with 50 percent of the trigone being covered by squamous metaplasia and some inflammatory fronds at the bladder neck. Both orifices appeared to be widely dilated and normal efflux of urine was noted during urethroscopy Following this testing a detailed consultation was conducted with the patient and her husband discussing her high-pressure detrusor instability and options for treatment.

25. She elected to initiate treatment with �Bladder Drill� or timed voiding. She was started on a every hour voiding schedule and taught to contract her levator ani muscles to try to suppress her involuntary detrusor contractions. However, after 3 weeks, she was unable to comply with this voiding schedule and we discussed pharmacotherapy. She felt 90% improved on tropsium chloride. She had mild dry mouth, but no other side-effects.

26. Case Study #9

29. The patient was able to contract her levator ani muscles voluntarily. There was no tenderness of the levators. Spontaneous uroflowmetry showed an obstructive pattern with a maximum flow rate of 14 ml/s as the patient voided 175ml over 25 seconds with a residual of 25 ml. Urinalysis and urine culture were negative.

30. After consultation with the patient and her daughter, the patient was started on vaginal estrogen cream, one gram nightly for six weeks prior to urodynamic evaluation. At the time of the patient�s urodynamic evaluation she noted some decrease in her urgency and urinary frequency but still had urge and stress incontinence complaints. Urethral closure pressure profiles showed the patient to have a functional urethral length of 2.8 cm and a closure pressure of 36cm H20. Leak point pressure testing showed a standing leak point pressure of 134 cm H20 with leakage at maximum cystometric capacity.

31. Both sitting and standing urethrocystometry revealed involuntary, uninhibited detrusor contractions resulting in leakage with a detrusor pressure of 18 cm H20. The patient reached a maximum cystometric capacity of 320 ml. The patient voided by urethral relaxation with a 22 cm H20 detrusor contraction with intermittent Valsalva.

32. Consultation was held with the patient and her daughter to discuss options for treatment of her mixed incontinence. We discussed treatment with behavioral therapy, antimuscarinics, and pelvic floor electrical stimulation.